How Much Will This Medical Procedure or Medical Test Cost Me? Part 1

Recently, I decided that I wanted to get a cardiopulmonary stress test for a baseline for my personal fitness program. Because the test is not for a medical indication, my health insurance won’t pay for it.

So I wanted to know how much it would cost me at a Pulmonary specialist’s office and figured I could just find out online.

It is a hard question, at least for me, to answer online.

[Spoiler Alert: I haven’t found out yet, so the answer is not in this post. This was my first attempt to answer the question. See How Much Will This Medical Procedure or Medical Test Cost Me? Part 2 (coming soon, I hope – when I have an answer for my friend.)]

A Cardiopulmonary Stress Test measures cardiac function during exercise as well as simultaneously measuring lung function during the exercise. [For more about the clinical indications for and the technique of performing cardiopulmonary stress testing please see my post Resources for The Uses of And Indications For A Cardiopulmonary Stress Test.]

My plan was to first go to the Medicare Site and see what Medicare pays for a Cardiopulmonary Stress Test.

This proved to be more difficult than I though – so far, I don’t have an answer. But I’ll keep working on it.

Before you can do any pricing research you need to know the CPT code (a number) that specifies what kind of test your doctor is ordering and that’s not easy. I don’t currently have access to the CPT 2015 Code Manual published by the American Medical Association.

I  went to the Medicare site and found the following PDF: Medicare Claims Processing Manual Chapter 23 – Fee Schedule Administration and Coding Requirements. And the problem with determining what the CPT code for your test is, requires what are called Long Descriptors. And there are restrictions on the display on the web of Long Descriptors because CPT codes are owned by the American Medical Association. See 20.7.1 – Displaying Material With CPT Codes for details:

In addition, when providing copies of publications in electronic media to any requesters in order to comply with Freedom of Information Act (FOIA) request, the publications released via FOIA that contain CPT codes must only contain short descriptions. CPT short descriptions mean CPT 5-digit identifying code numbers and abbreviated procedural descriptions that are no more than 28 characters long. When contractors provide any electronic media to other State and Federal agencies, any CPT coding contained in the
publication(s) must conform to these requirements. Contractors must notify such Federal and State Agencies that their use is subject to the terms of the amendment.

20.7.2 – Use of CPT Codes With Long Descriptors
(Rev. 1, 10-01-03):

Fee schedules cannot include long descriptions. Only CPT short descriptions (28 characters or less) can be used in fee schedules.

From the above, it seems to me, that it would be very difficult for a healthcare concsumer to determine how much traditional Medicare is paying for a service.

Below are short descriptors that I found for pulmonary stress test. Note there is not enough information to determine each procedure consists of, so I don’t think you could price them.

For a pulmonary stress test there are two flavors:

94620: Pulmonary Stress Test/Simple

94620: Pulmonary Stress Test/Complex

The CPT codes are listed in the CPT Manuals (published by and updated yearly by the American Medical Association). See the Coding and Reimbursement webpage at the AMA Store for purchase information.

I found the following website with cost information: Indianapolis, IN: Pulmonary Tests (Stress Test) Cost Comparison from New Choice Health. I don’t know how reliable the information is. I suggested my friend call each of providers he was considering for the service, and verify the price.

The above website sends your health insurance information and the applicable CPT code to facilities that pay the website for leads.

When you complete the request form, you recieve the following response from the website:

We have received your request. Thank you!

Next Steps

You will receive an email confirming your request.
The details of your quote request will be sent to our partners.
Our partners will contact you with specific procedure pricing in responses to your request.
You decide which facility you want to use for your medical procedure and schedule your procedure directly with that facility.

Websites with medical procedure price information include the following from The Centers for Medicare and Medicaid:

Physician Fee Schedule from – The Centers for Medicare and Medicaid.

Overview of the Physician Fee Schedule Look-Up Tool from – The Centers for Medicare and Medicaid.

How to Use the Searchable Medicare Physician Fee Schedule (MPFS)  [Full Text PDF] from the Medicare Learning Network – Official Information Health Care Professionals Can Trust. On pp. 17 + 18 of the PDF there are a number of other Medicare Learning Network Resources.

Additional Resources:

That Medical Test Costs $50, or Is It $500? NYT

JAMA. 2014 Oct 22-29;312(16):1670-6. doi: 10.1001/jama.2014.13373.
Association between availability of health service prices and payments for these services. [PubMed Abstract] [Full Text HTML] Whaley C1, Schneider Chafen J2, Pinkard S3, Kellerman G3, Bravata D2, Kocher R4, Sood N5.

Health Aff (Millwood). 2014 Aug;33(8):1391-8. doi: 10.1377/hlthaff.2014.0168.
Price transparency for MRIs increased use of less costly providers and triggered provider competition. [PubMed Abstract]
Wu SJ1, Sylwestrzak G2, Shah C3, DeVries A4.

Insured, but Not Covered NYT

Paying Til It Hurts, NYT facebook group on healthcare costs

How to Manage Increasingly Higher Medical Deductibles
SEPT. 25, 2015, NYT

Revealing a Health Care Secret: The Price 

This entry was posted in Healthcare Economics. Bookmark the permalink.