Claims data - definition of physician visit

I am doing some analysis on number of specialist visits and primary care visits, and I’m wondering what the usual way of handling claims that are something other than a visit (are not coded as a visit) yet they take place in a physician’s office. Immunizations are a big one, but there are lots of others. Procedures performed in the office, etc.
My thought is to count each of these claims as a visit. What do you all think? Can you point me to a resource that discusses such things? I’ve been unable to find anything.

I am confused by the logic these are not recorded as visits.

Secondly, I could get multiple tests, including vaccines - if you add visit to each, wouldn’t you be double counting?

So is the benefit a physician visit? Or is the benefit for diagnostic tests, immunizations, etc.?

If the benefit is for a physician visit, count 1 visit per day for a particular physician, even if they got tests or shots or whatever. But if they went to a PCP and a specialist on the same day, that is 2 visits. (Unless the plan is limited to one visit per day.)

If the benefit is for each thing that happens, then you count the shot, the lab, etc., plus the visit.

This from the perspective of someone who prices a lot of “not major medical” products that have physician visit benefits.

Also—-ask the Benefits dept how they pay them. (Unless they are asking you how they are supposed to pay them. In that case consult the policy language and ask Compliance or Legal what the intent was if it’s unclear.)

I’m going to change the terminology I’m using, hopefully to make it clearer.

A physician office claim is everything done for the same patient on the same day at a physician’s office. A claim is typically comprised of multiple records (for billing purposes). Often, there will be a “visit” as one of the records, and those are the easy ones. All of the stuff done for that patient on that day is part of the same claim. Where my question comes in is on claims that don’t have a “visit” record. I have to decide if those count as a claim or not for the purposes of what I’m trying to look at. It’s very common to have a claim with “immunization” records (and no “visit” record). There are lots of other things, say, simple procedures done in the office, screenings, etc. These are completed by the physician and/or support staff so I want to count those claims for my study. I want to exclude claims that only have xrays or labs (no records for “visit” or other things I want to count) for example.

It’s been helpful to talk through this here. Please let me know if there’s something I’m missing in my approach, or if you know of any books etc that guide the researcher how to handle the details of claims data regarding services provided in the physicians’ office.

1 Like

What is the purpose of this project?

I recently needed to get some imaging done as ordered by a specialist. While on seemingly endless hold to get it scheduled the recorded message mentioned roughly 1,647 times that they could do my mammogram (for which I was overdue) at the same time as my other imaging. So I did and had the initial imaging sent to the first specialist and the mammogram results sent to my ob-gyn.

No reason they were done on the same day other than saving me a trip.

Do you want that to count as 0 visits, 1 visit, or 2 visits?

On the other hand the same physician ordered two other tests which were both done at the physician’s other location on a different day from the initial visit, without the physician present, but both tests done at the same time. Again, are you counting that as 0, 1, or 2?

What about when I went to Africa and got like 5 vaccines at a travel clinic one one day, 2 more a month later, and some Rx’s for another vaccination (that was taken orally) and malaria pills? 0 visits? 2 visits (two times to the travel clinic)? 3 visits? (Counting the pharmacy) 6 visits? (number of diseases I was inoculated against) 7 visits? (One per shot) 8 visits? (One per shot plus the oral vaccination) 9 visits? (Prior 8 plus the malaria pills, which aren’t an innoculation)

Or are you asking us how to count it? If so why do you care how many visits? Not understanding what you’re trying to accomplish I have no idea how to answer.

I’m comparing the number of specialist visits / contacts before and after a new primary care option became available, to see what the effect of the option is on specialist utilization.

In that case you really only care about the customer SEEING the specialist/primary care dr, and not what was done.

To answer your base question, there is no industry standard on how to count office visits. There are two primary ways I’ve used. 1) look for office visit CPT codes (99201-99215 IIRC) ans map the provider over to a specialty or assign them as PCP. B) determine all of the providers seen on a given day, narrow that down to just doctors (remove facilities, NPs, dentists, pharmacists, etc.), and then count once per doctor per day. Map over those docs to a specialty or assign them as PCPs.

It is very likely that you will have a ton of garbage data for the rendering provider. It is also likely that whatever you are using to map a doc to a specialty will be garbage as well. If I was you, I’d follow Ajstudies advice and find out how your claims system knows the difference between a specialist visit and a normal office visit. Your plan likely has different benefits for the two so there is a way to separate in the claims system and you should be able to leverage that logic to build your OV and specialist visit counts. Once, I wrote some code that identified specialist versus OV by looking at the copay amount from the claim as an OV was like a $25 copay and the specialist visit was $45. That is not ideal but I was limited because of the data provided to me. Since what you are really interested in is a change in the claim payment pattern, it is best to start with how the claims are paid.

BTW, telehealth has it’s own set of CPT codes not related to OV codes.

1 Like

Find the entire encounter imo. My PCP bills separate from Labs/rad, etc…even though it is the same provider tax id
What I do is sort by MemberID, Incurred date and Provider TaxID and Provider NPI. Then manipulate from there
Oh, some women use their OB/GYN as their PCP. Thus the specialist garbage from above.