ED Coding and Reimbursement Alert

CMS is not in favor of billing for services administered to family members.

Chances are that your ED physician is likely to see family members as patients. After all, in many towns, there’s only one emergency department available, and emergencies do happen. But when it comes to coding those claims, there are specific criteria you must follow to stay on the right side of Medicare’s compliance regulations.

First, Check State Ethics Guidelines

Before you treat a family member, find out where your state medical society stands on the issue. The American Medical Association’s Council on Ethical and Judicial Affairs states, “Physicians generally should not treat themselves or members of their immediate families if there are other choices for treatment. Professional objectivity may be compromised when an immediate family member or the physician is the patient; the physician’s personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered.”

Your state medical association may have its own guidelines on these situations, which you should consult before treating family members. If you happen to encounter any gray area when you read the guidelines, consult a legal professional to determine whether you should be treating family members at all.

Next, Evaluate Insurance Stance

If you determine you’re within your legal and ethical guidelines to treat a family member, it’s time to review where Medicare stands on the topic. “Medicare does not allow providers to bill the insurance for immediate family members,” says Gina Vanderwall, OCS, CPC, CPPM, a medical financial counselor in Canandaigua, New York. Those services are to be provided free of charge, assuming the patient falls under Medicare’s definition of what constitutes a family member.

In black and white: Section 2332 of the Medicare Carriers Manual includes “Charges Imposed by Immediate Relatives of the Patient or Members of the Patient’s Household” as being excluded from coverage. “The intent of this exclusion is to bar Medicare payment for items and services that would ordinarily be furnished gratuitously because of the relationship of the beneficiary to the person imposing the charge,” the agency states. “This exclusion applies to items and services rendered by providers to immediate relatives of the owner(s) of the provider. It also applies to services rendered by physicians to their immediate relatives and items furnished by suppliers to immediate relatives of the owner(s) of the supplier.”

Here’s how Medicare defines a family member: CMS includes the following relationships within the definition of “immediate relative:”

• Husband and wife
• Natural or adoptive parent, child, and sibling
• Stepparent, stepchild, stepbrother, and stepsister
• Father-in-law
• Mother-in-law
• Son-in-law
• Daughter-in-law
• Brother-in-law
• Sister-in-law
• Grandparent and grandchild
• Spouse of grandparent and grandchild

Many other insurers maintain similar guidelines about submitting claims for family members, so if you’re dealing with private insurers or other companies, check with your payers’ provider relations departments before sending in any such claims. If the verbiage in your contracts is unclear, consult an attorney for legal advice on the topic.