Billing Rules Change when the Patient Isn’t Present

Know the best coding approach when a family member or caretaker is present on a patient’s behalf.

Typically, insurers (including Medicare) will not cover an evaluation and management (E/M) service with a patient’s family or caretaker(s) if the patient is not present. In such a case, the best approach to ensure reimbursement is to not file a claim with insurance, but rather to bill the family member(s) who are present for the visit.
You should inform the family member(s) that the service is not billable to the insurance company, and therefore will be provided at his or her expense. Explain this prior to scheduling the appointment, so there are no surprises when the bill arrives. If the family member/caretaker isn’t a patient, obtain his or her demographic information so you may enter it into your practice management system.

Select E/M Codes Based on Time

You may report visits with family members and caretakers using typical E/M service codes, based on time. Per CPT® instructions:
When counseling and/or coordination of care dominates (more than 50 percent) the encounter with the patient and/or family (face-to-face time in the office or other outpatient setting on floor/unit time in the hospital or nursing facility) then time shall be considered a key or controlling factor to qualify for a particular level of E/M service. This includes time spent with parties who have assumed responsibility for the care of the patient or decision-making whether or not they are family members (e.g., foster parents, person acting in loco parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the patient’s medical record.
Counseling is a discussion with a patient and/or family concerning one or more of the following:

  • Diagnostic results, impression, and/or recommended diagnostic studies
  • Prognosis
  • Risk and benefits of management (treatment) options
  • Instructions for management (treatment) and/or follow up
  • Importance of compliance with chosen management (treatment) options
  • Risk factor reduction
  • Patient and family education

The provider should document in the medical record, all pertinent information discussed during the session. For example, “30 minutes of counseling” isn’t sufficient. Instead, the provider should summarize the discussion that comprises the counseling or coordination of care. In a best-case scenario, the provider also will document the beginning and ending time of the counseling and/or coordination of care, and the beginning and ending time for the overall face-to-face visit.
Because the patient is the focus of the visit, you should bill an established level of E/M visit (e.g., 99211–99215). When reporting E/M services by time (rather than the key components of history, exam, and medical decision-making), use CPT® “reference times” to determine an appropriate E/M service level.
99211 = 5 minutes
99212 = 10 minutes
99213 = 15 minutes
99214 = 25 minutes
99215 = 40 minutes
CPT® states, “When codes are ranked in sequential typical times and the actual time is between two typical times, the code with the typical time closest to the actual time is used.” For example, a level III established patient outpatient visit (99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity) has a reference time of 15 minutes, while a level IV service (99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity) has a reference time of 25 minutes. When reporting a time-based E/M lasting 19 minutes, you would report 99213.
As an example of how such a visit might be documented and coded, consider the following sample note:
Family discussion on 5/10/2014 with Jane Doe (daughter) and Joe Doe (son) regarding their mother Mary Doe, MRN # 12345, DOB 2/2/45. Mary is a current patient of mine who was recently diagnosed with CA of the left breast that is very aggressive. I discussed prognosis and treatment options for Mary’s aggressive breast CA, including surgery, recovery time, and chemotherapy; and the side effects of chemotherapy. I gave them literature from the American Cancer Society, and the name of local support groups that they could contact. I spent a total of 42 minutes with Jane and Joe. Both parties verbalized understanding. I answered all their questions, and they are in agreement with my plan, as outlined above.
Proper code selection is 99215 (with a reference time of 40 minutes).
Roxanne Thames, CPC, CEMC, has worked in the medical billing and coding field for 20 years. She began her career as a billing office clerk for a nursing home, and later worked as a physician biller/coder for a large internal medicine practice in Lemoyne, Pa. She has taught ICD-9-CM at Harrisburg Area Community College, and now works as an auditor/educator for a practice management group. She is an active member in the York, Pa., local chapter, and enjoys mentoring, networking, and visiting with other local chapters.

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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

4 Responses to “Billing Rules Change when the Patient Isn’t Present”

  1. jane says:

    I am confused by this article, “Billing Rules Change when the Patient Isn’t Present”. The first part states that “typically, insurers (including Medicare) will not cover an evaluation and management (E/M) service with a patient’s family or caretaker(s) if the patient is not present.” Then in the second section, it states the opposite. What rules changed and is it or is it not permissible to bill for a doctor’s time when he spends time counseling the parent of a disabled patient?

  2. Kimberly Nichols says:

    I am having a hard time finding CMS policy on patient must be present. I know I have seen it before but now need to share with co-workers. Do you have the CMS information or a link to the site that states this?

  3. Sara says:

    I have pts being taken care of by my Cardiologist in the hospital but not face to face interaction is taking place. When asked what is happening they are simply speaking to the nursing staff and no pt contact during visit. These pts are in the COVID 19 Units. Can we bill any service for this visit without pt and/or family interaction? I am not seeing an EM Code to do so?

  4. Lee Fifield says:

    Hi, Sara. AAPC is only able to answer questions that pertain directly to the content within the article. Please refer to our COVID-19 articles here or reach out to our Ask an Expert team.