Reading Your Doctor's Medical Services Receipt

You've just spent an hour at your doctor's office. As you leave, you are handed a piece of paper. It has tiny typed words and lots of little numbers and may be one part of a multi-part form. To us patients, it looks like a doctor's appointment receipt for services. Your doctor's staff may call it an encounter form, a billing slip, a superbill, or an after-visit summary.

Hospital receipts may look similar to a doctor's medical services reciept, although far more extensive. It doesn't really matter what they look like; the information on both documents will be the same kind of information.

You can use your doctor's medical services receipt to understand the services that were performed.

You can also use the receipt to help you compare the services performed during your doctor's visit, to the services listed on your health insurer's Explanation of Benefits (EOB), to be sure you aren't being charged any more money than you should be.

Information You'll Find on the Doctor's Medical Services Receipt

Your doctor's medical services receipt will reflect everything that happened during your appointment and will order some or all of the follow-up tests or treatments that need to take place, too. On the receipt, you will find:

  • Your personal information including your insurance information (not shown). When the receipt is handed to you, you'll want to make sure it's yours and hasn't been mixed up with someone else's reciept.
  • Names and CPT (current procedural terminology) codes for the services performed
  • Names and CPT codes for tests being ordered
  • International Classification of Diseases (ICD) codes, either ICD-9 codes or ICD-10 codes (which are used for diagnoses)
  • Other sections for items such as co-payment information and signature.
1

Take a Look at the Services Listed

list of services on a superbill
Trisha Torrey

Each type of practice, whether it's primary care or specialty care, will have a different set of services and codes on it, depending on the types of services they perform and the body system or diseases they address.

This form is a primary care form, and can include a wide variety of services from basic check-ups, to basic test orders, to basic diagnoses.

This graphic shows a small portion of the services listed on this doctor's receipt. If you're uncertain of the services listed, you can visit the American Association for Clinical Chemistry for an explanation of medical tests or you can use an online medical dictionary, such as MegaLexia.

Take a look at the services on your receipt that have circles or checkmarks or some designation that they have been performed or ordered. Think back through the time you've just spent with your doctor and others in the office to be sure you concur with the receipt. For example, if you see "allergy injection" checked off, and you didn't receive any injections, you'll want to inquire about why that is on your reciept. This will be even more important later when you receive the doctor's bill.

Now let's take a look at the CPT codes, those five-digit numbers listed next to each service.

2

CPT Codes Are Listed

list of CPT codes on a superbill
Trisha Torrey

Once you have identified the services and follow-up services on your bill, you'll see that each one is lined up with a five-digit code.

These are called CPT codes. Every single service a doctor will provide to you (that he expects to be paid for) will align with one of these CPT codes.

CPT codes are important to your doctor because they determine how much he will be paid for your visit. They are important to you because you want to be sure they are reflected accurately on your records. The wrong CPT codes can cause a ripple effect that might end up in the wrong diagnosis for you, the wrong treatment, and later, if you ever need to change insurance, it could cause a denial of insurance for pre-existing conditions.

Just as you double checked the names of the services and follow-up services provided, you'll want to make sure the CPT codes are correct, too. Link here if you'd like to identify CPT codes to find out what services are represented by what codes.

If you find a discrepancy, you'll need to work with your doctor's office to correct your medical record.

Once you have the services and CPT codes covered, it will be time to take a look at the diagnosis information.

3

Your Diagnosis Is Listed

your diagnosis is listed on your appointment receipt
Trisha Torrey

In a separate section from the services and tests, you'll find a list of diagnoses. As mentioned before, these diagnoses will be found on a primary care receipt. Other specialists will have different diagnoses on their receipts, depending on the body system and diseases they work with.

In order to be paid by your insurer, Medicare, or other payer, the doctor must designate a diagnosis. When you review your doctor's bill, you will understand the importance of making sure that the services performed line up with the diagnosis you've been given. This can become problematic for two reasons.

The first reason is that you may not yet have been diagnosed. That means your doctor will be taking an educated guess at this point. Unfortunately, for more difficult to diagnose health problems, this guess can color any other professional's regard of the real problem.

Secondly, this diagnosis, even if preliminary, will be recorded in your records. Whether or not it is correct, it can have an effect on your future ability to get insurance if it reflects the possibility of a pre-existing condition.

For those reasons, you'll want to double check that the diagnosis has been recorded as accurately as possible. You may find your doctor hasn't checked off a diagnosis in the list; instead, he may have written it in a blank space elsewhere on the receipt.

If you find a discrepancy, you'll need to work with your doctor's office to correct your medical record.

Once you've seen the words used to describe your diagnosis, you'll want to double check the ICD code, a completely different code system that doctors use.

4

Line up the ICD-9 or ICD-10 Codes

check the icd codes on your appointment receipt
Trisha Torrey

ICD codes are the codes that designate your diagnosis. These codes change over time, so they have a number appended to them to show which set of codes is being used. The ICD-9 code set was replaced by the more detailed ICD-10 code set on October 1, 2015.

The ICD codes are comprised of four or five characters with a decimal point. You'll find them next to the names of diagnoses on the appointment receipt.

Like CPT codes, the words for your diagnosis, and the codes for your diagnosis must match.

If you match the ICD 9 or ICD 10 codes to the words your doctor has written and spoken to you and find a discrepancy, then call it to your doctor's attention immediately and ask for the error to be corrected. You can't afford to have these codes be replicated in paperwork that may affect your ability to get the care you need, or the insurance you need, in the future.

Now that you understand the information on this doctor's medical services receipt, your next step will be to compare your doctor's receipt to your doctor's bill, and later the EOB that comes from your health insurer.

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  1. Centers for Medicare and Medicaid Services. ICD-10. Updated March 6, 2020.