General Checkup
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General Checkup Receipt Example
This receipt documents a CPT 99213 established patient office visit for a general checkup at Northside Family Medicine. The provider billed $175.00; the contractual adjustment of $62.25 brings the allowed amount to $112.75. Blue Cross PPO paid $82.75, leaving a $30.00 primary care copay as the patient responsibility. The receipt is HSA and FSA eligible.
This general checkup receipt documents an annual physical (CPT 99396 for adult preventive visit) billed at $285, with $235 insurance adjustment and $50 patient copay. The receipt includes ICD-10 code Z00.00 (general adult medical exam), provider NPI, and an HSA-eligible flag for FSA/HSA reimbursement.
Receipt Breakdown
What Makes This Receipt Realistic
- • CPT 99213: Level 3 established patient visit, the most common outpatient code
- • Contractual adjustment shown separately, not buried in the billed amount
- • ICD-10 Z00.00: standard diagnosis code for general adult medical examination
- • Provider NPI included in receipt header
- • HSA/FSA eligibility noted for reimbursement purposes
- • Math: $112.75 allowed − $82.75 ins paid = $30.00 patient copay
Frequently Asked Questions
What does this general checkup receipt show?
This receipt documents a general checkup at Northside Family Medicine, 2200 N. Lincoln Ave, Chicago, IL 60614 (NPI: 1234567890). Patient: James R. Sullivan. Date of Service: June 5, 2025. CPT 99213: Office Visit, Established Patient, Level 3. ICD-10: Z00.00 (General adult medical examination). Billed: $175.00. Contractual Adjustment: −$62.25. Allowed Amount: $112.75. Insurance Paid (Blue Cross PPO): −$82.75. Patient Copay: $30.00. HSA/FSA Eligible. Balance Due: $0.00.
What is the contractual adjustment on a medical receipt?
The contractual adjustment (also called the insurance discount or write-off) is the amount the provider agreed to accept less than the billed charge as part of their in-network contract with the insurer. In this example, Northside Family Medicine billed $175.00 but agreed to accept $112.75 as the full allowed amount, the $62.25 difference is written off and neither the insurer nor the patient owes it. The contractual adjustment is not the patient's responsibility. Only the allowed amount ($112.75) is split between the insurance payment ($82.75) and the patient copay ($30.00).
Is a general checkup receipt eligible for HSA or FSA reimbursement?
Yes. Office visit copays for general checkups are qualified medical expenses under IRS Publication 502, fully eligible for HSA and FSA reimbursement. Your plan administrator needs an itemized receipt showing the date of service, provider name, CPT code or service description, and the patient responsibility amount. The receipt does not need to show the insurance payment or contractual adjustment, just the date, provider, service description, and $30.00 copay. Annual preventive care visits may be covered at 100% with no copay under ACA-compliant plans, depending on how the visit is coded.