Cost and Quality Information for Health Care Consumers In Compliance Wisconsin Act 146
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- Briana Houston
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1 Cost and Quality Information for Health Care Consumers In Compliance Wisconsin Act 146 Wisconsin Act 146 seeks to make health care costs and charges clearer to consumers. It requires health care providers to disclose, upon request, certain charge and payment information for health care services, tests, and procedures. Health insurance plans will often reimburse your provider for less than the full charge. Consumers may be responsible for some or all of the rest. How much you are responsible for depends on the details of your insurance, such as your deductible and your co-payment responsibilities. Your insurance plan is required to advise you on your possible actual costs. You must tell your insurer the exact health care services you are considering. Your health care provider can give you the technical descriptions ( CPT codes ). Act 146 also requires health care providers to offer information on charges, payments, and possibly on their comparative quality. The Wisconsin Department of Health Services determined that this requirement will be phased in, beginning in 2011 with physicians. This physicians report is based on the 25 most common medical conditions (without complications) treated by physicians in Wisconsin among those under age 65. For each medical condition, the five Related Medical Services are listed that account for most charges by physicians. (Again, assuming there are no complications.) You probably will not require all of these services or even any of them, depending on your physician s judgment and your decisions. Your physician also may recommend additional services and supplies from some other health care provider. Patients should ask their physician what might be provided or recommended for their unique situation. s for specific services ( CPT codes ) are available from this practice on request, if it is a service provided by this practice. There are important notes and definitions following the table.
2 Routine Exam Patient Age 1 4 (99392) Patient Age 5 11 (99393) Patient Age (99395) Patient Age (99396) Screening Mammography Bilateral Professional and Tech Comp (77057) Screening Mammography Bilateral Professional Comp Only ( ) Hyperlipidemia, Other Patient, Age (99396) Comprehensive Metabolic Panel (80053) Lipid Panel (80061)
3 Hypertension Office Outpatient, Established Patient, Level 4 (99214) Patient, Age (99396) Comprehensive Metabolic Panel (80053) Echocardiography, transthoracic, real time with documentation (2D), M Mode Compl Spec&Color Dop (93306) Echocardiography, transthoracic, real time with documentation (2D), M Mode Compl Spec&Color Dop Professional Comp Only ( ) Other Minor orthopedic Disorders Back MRI Spinal Canal & Contents, Lumbar; without contrast material (72148) MRI Spinal Canal & Contents, Lumbar; without contrast material Professional Comp Only ( ) Chiropractic Manipulative Treatment, Spinal, 1 2 regions (98940) Chiropractic Manipulative Treatment, Spinal, 3 4 regions (98941) Therapeutic Procedure, 1 or more Areas Each 15 Min, Therapy Exercises (97110) Overall:
4 Joint Degeneration, Localized Back, w/o surgery MRI Spinal Canal & Contents, Lumbar; without contrast material (72148) MRI Spinal Canal & Contents, Lumbar; without contrast material Professional Comp Only ( ) Chiropractic Manipulative Treatment, Spinal, 1 2 regions (98940) Chiropractic Manipulative Treatment, Spinal, 3 4 regions (98941) Therapeutic Procedure, 1 or more Areas Each 15 Min, Therapy Exercises (97110) Isolated Signs, Symptoms & Non Specific Diagnosis or Conditions MRI Brain (including Brain Stem), without contrast, followed by contrast (70553) MRI Brain (including Brain Stem), without contrast, followed by contrast Professional Comp Only ( ) Radiologic Exam, Chest 2 Views Front & Lat (71020) Radiologic Exam, Chest 2 Views Front & Lat, Technical Comp Only (71020 TC) Radiologic Exam, Chest 2 Views Front & Lat, Professional Comp Only ( ) Screening Mammography Bilateral (77057)
5 Screening Mammography Bilateral Professional Comp Only ( ) Diabetes, w/o surgery Lipid Panel (80061) Albumin Urine Microalbumin Quantitative (82043) Hemoglobin Glycosylated (83036) Overall: Obesity, w/o surgery Patient Age (99396) Lipid Panel (80061) Polysomnography Sleep Staging with 4 or more Addtnl Parameters with Cpap attended by technologist, Professional Comp Only ( ) Polysomnography Sleep Staging with 4 or more Addtnl Parameters with Cpap attended by technologist, Technical Comp Only (95811 TC)
6 Hypo functioning Thyroid Gland, w/o surgery Patient Age (99396) Lipid Panel (80061) Thyroid Stimulating Hormone (84443) Acne Patient, Level 2 (99212) Office Outpatient Visit, New Patient, Level 2 (99202) Office Outpatient Visit, New Patient, Level 3 (99203)
7 Acute Bronchitis Emergency Dept, High Severity & Urgent Evaluation (99284) Radiologic Exam, Chest 2 Views Front & Lat (71020) Radiologic Exam, Chest 2 Views Front & Lat, Professional Comp Only ( ) Pressurized or Non Pressurized Inhalation Treatment (94640) Acute Sinusitis, w/o surgery Office Outpatient Visit, New Patient, Level 3 (99203) CT Scan, Maxillofacial Area, Without Contrast Material (70486) CT Scan, Maxillofacial Area, Without Contrast Material, Professional Comp Only ( ) Supervision of Prep and Provision of Antigens for Allergen Immunotherapy, Single or Multiple Antigens (95165)
8 Chronic Sinusitis, w/o surgery Nasal Endoscopy Diagnostic Unilateral or Bilateral, Separate Procedure (31231) CT Scan, Maxillofacial Area, Without Contrast Material (70486) CT Scan, Maxillofacial Area, Without Contrast Material, Professional Comp Only ( ) Percutaneous Tests with Allergenic Extracts, per test, total may vary (95004) Tonsillitis, Adenoiditis or Pharyngitis, w/o surgery Emergency Dept, High Severity & Urgent Evaluation (99284) Culture Presumptive, Pathogenic Organisms, Screening Only (87081) Microbiology, Streptococcus Group A (87880)
9 Otitis Media, w/o surgery Patient, Level 2 (99212) Emergency Dept, Moderate Severity (99283) Tympanostomy (69436) Otolaryngology Diseases Signs & Symptoms Emergency Dept, Moderate Severity (99283) Control Nasal Hemorrhage Anterior Simple (30901) Nasal/Sinus Endoscopy, Surgical With Control of Nasal Hemrrg (31238)
10 Routine Inoculation Patient Age (99395) Patient Age (99396) Immunization Administration, 1 Vaccine (90471) Human Papilloma Virus Vaccine, Quadrivalent, 3 Dose Schedule, Intramuscular (90649) Tetanus, Diphtheria Toxoids and Acellular Pertussis Vaccine, Age 7 or older, Intramuscular (90715) Contraceptive Management Patient Age (99395) Insertion of Intrauterine Device, Note: Does not include separate charge of IUD (58300) Ultrasound, Transvaginal (76830) Ultrasound, Transvaginal, Professional Comp Only ( )
11 Gastroenterology Diseases Signs and Symptoms Scope Of Colon For Diagnosis (45378) CT Scan of Pelvis With Contrast (72193) CT Scan of Pelvis With Contrast Professional Comp Only ( ) CT Scan of Abdomen with Contrast (74160) CT Scan of Abdomen with Contrast Professional Comp Only ( ) Fungal Skin Infection Patient, Level 2 (99212) Debridement of Nail Any Method, 6 or more (11721) Excision Nail Matrix, Permanent Removal (11750)
12 Mood Disorder, Depressed Psychiatric Diagnosis Interview Exam (90801) Insight Oriented, Behavior Modifying and/or Supportive Psychotherapy with Medical Evaluation and Management Services (90805) Individual Psychotherapy, Insight Oriented, Behavior Modifying and/or Supportive, In Office Outpatient Facility (90806) Pharmacologic Management, Minimal Medical Psychotherapy (90862) Other neuropsychological or Behavioral Disorders Psychiatric Diagnosis Interview Exam (90801) Individual Psychotherapy, Insight Oriented, Behavior Modifying and/or Supportive, In Office Outpatient Facility (90806) Family Psychotherapy With Patient Present (90847)
13 Visual Disturbances, w/o surgery Ophthalmological Services, Medical Exam and Eval, Comprehensive, New Patient, 1 or more Visits (92004) Ophthalmological Medical Exam and Eval, Established Patient (92012) Ophthalmological Medical Exam and Eval, Comprehensive, Established Patient, 1 or more Visits (92014) Deter Refractive State (9 Cataract, w/o surgery Ophthalmological Services, Medical Exam and Eval, Comprehensive, New Patient, 1 or more Visits (92004) Ophthalmological Medical Exam and Eval, Comprehensive, Established Patient, 1 or more Visits (92014) Deter Refractive State (
14 Inflammatory Eye Disease, w/o surgery Ophthalmological Services, Medical Exam and Eval, Comprehensive, New Patient, 1 or more Visits (92004) Ophthalmological Medical Exam and Eval, Comprehensive, Established Patient, 1 or more Visits (92014) Deter Refractive State (
15 Important Notes: The most common conditions and related medical services. If your condition is listed, you can see some common services provided by physicians to diagnosis and treat that condition, assuming there are no medical complications. The CPT code is used by insurers to determine their reimbursement to the physician. If you provide this code to your insurer, they will tell you what part of the charge they will pay and how much you may be responsible for at this time. The actual services for a given condition may be different from those listed. Other related services and supplies. Many conditions require medical services and supplies from other physicians and other providers (prescription drugs, for example). Your physician can tell you what other services and supplies may be recommended for your treatment, but you should consult the other providers and your insurer if you want an estimate of the probable cost to you. Additional charges may include facility costs, diagnostic testing (such as radiology or lab work), anesthesia administration, and so on. Your financial responsibility will depend on your insurance plan and on payment plans negotiated between insurers and providers. Not applicable or NA this physician either does not treat this condition, does not provide this service or could be a non-covered benefit under. The current charge is the standard amount this physician charges for this service. Individual charges may be lower or higher, depending on the individual s medical condition. This is not a required part of this report. The median billed charge is required by Act 146. It is this physician s charge in effect during the first half of If the charge changed during this period, it is the middle of the charges that were in effect. The payment is how much will pay this physician for the listed service, each time. The is the average payment for a particular service to a particular provider after the application of discounts, other contractual amounts, less any patient deductible amounts, coinsurance amounts or copay amounts. Reports on quality may be publically available for this physician s services. If so, here is how you can obtain them. The Wisconsin Department of Health Services defined the methods for calculating this information and determined that this report will be phased in, beginning in March 2011 with physicians. More information is available at
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