As professionals, we have the privilege to practice medicine and are required to charge a legitimate and ethical professional fee for consultation as prescribed by Code of Ethics Regulations. A breach of these ethics regulations is professional misconduct.

“3.7.1 A physician shall clearly display his fees and other charges on the board of his chamber and/or the hospitals he is visiting. Prescription should also make clear if the Physician himself dispensed any medicine.

1.8 Payment of Professional Services: The physician, engaged in the practice of medicine shall give priority to the interests of patients. The personal financial interests of a physician should not conflict with the medical interests of patients. A physician should announce his fees before rendering service and not after the operation or treatment is under way. Remuneration received for such services should be in the form and amount specifically announced to the patient at the time the service is rendered. It is unethical to enter into a contract of "no cure no payment". Physician rendering service on behalf of the state shall refrain from anticipating or accepting any consideration.”

But, what is a legitimate consultation fee structure? What factors should be taken into account when deciding charges?

Medicare in the United States (equivalent of Mediclaim in India) has clarified how a consultation will be charged and reimbursed in the US.

The Current Procedural Terminology (CPT) has defined four types of consultation: Office or other outpatient, initial inpatient, follow-up inpatient and lastly confirmatory consultation (also called a second opinion). Five levels have been described for each type of consultation, based on patient history, physical examination and medical decision making.

The Current Procedural Terminology (CPT) code set is a medical code set maintained by the American Medical Association (AMA). These codes are the standards followed by medical professionals in the US and are used to bill outpatient and office procedures and help the insurers to determine the amount of reimbursement that a practitioner will receive for services provided.

The five levels are as follows:

1. Level 1 Established Office Visit: This is the lowest level of care for established patients in the office and accounts for only 3.21% of consults. Usually the presenting problems are minimal.  It is the only one which does NOT REQUIRE THE PRESENCE OF THE PHYSICIAN.  There are no specific documentation requirements, but the purpose of the visit should be recorded. (US Medicare allowable reimbursement for this level of care is $20.05)
2. Level 2 Established Office Visit:This is the second lowest level of care for an established patient being seen in the office and is used for 3.1% of patients. Usually the presenting problems are self-limited or minor.  The Medicare allowable reimbursement for this code is $43.68. Documentation requires TWO out of THREE of the following:  Problem-focused History, Problem-focused Exam, Straightforward Medical Decision-Making or 10 minutes spent face-to-face with the patient if coding based on time. 
3. Level 3 Established Office Visit: This level of care is located “in the middle’ of the coding spectrum for office visits with established patients.  It involves 41.78% of patients. Usually the presenting problems are of low to moderate severity.  The reimbursement for this level of care is $73.40. The documentation for this encounter requires TWO out of THREE of the following:  Expanded Problem-focused History, Expanded Problem-focused Exam or Low Complexity Medical Decision-Making or 15 minutes spent face-to-face with the patient
4. Level 4 Established Office Visit:This code represents the second highest level of care for established office patients. This is the most frequently used code in 47.41% of established office patients. The Medicare allowable reimbursement for this service is $108.13. Usually the presenting problems are of moderate to high severity. The documentation for this encounter requires TWO out of THREE of the following:  Detailed History, Detailed Exam, Moderate Complexity Medical Decision-Making 0r 25 minutes spent face-to-face with the patient if coding based on time.
5. Level 5 Office Visit:The highest level of care for established patients being seen in the office.  It involves 9% of established office patient visits. The Medicare allowable reimbursement for this level of care is $145.72. The documentation for this encounter requires TWO out of THREE of the following:  Comprehensive History, Comprehensive Exam, High Complexity Medical Decision-Making or 40 minutes spent face-to-face with the patient if coding based on time.

India does not have such a well-defined structure for reimbursement for doctors for services provided. The CGHS pays a very meager amount and that too is delayed for months together and is given without any interest.

The Association should debate and come out with such a fee structure if not the same.

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA