General Surgery Coding Alert

Question: My surgeon met with an elderly patients family to discuss treatment options and the patients plan of care. The patient was not present for this inoffice meeting. Can I still bill Medicare an E/M service based on the time spent with the family? What about if a patient is there with the family but due to cognitive issues is not mentally present or participating?

Vermont Subscriber

Answer: CPT does allow you to report new and established patient office visits without the patient present. When counseling and/or coordination of care account for more than 50 percent of the face-to-face time that the physician spends with the patient and/or family, you may use time as the key factor when determining the E/M service level. In these cases, you do not have to use history, examination, and medical decision making as the key factors. Because counseling comprises the majority of the visit you describe, you should assign 99212-99215 (Office or other outpatient visit for the E/M of an established patient &) based on time.

Downside: Medicare will only pay for the office visit if the patient is present. Your surgeon needs to document the face-to-face time with the patient in order for you to bill the E/M services based on time spent on coordination and care.

Medicare requirements specify that the physician must meet face-to-face with the patient to report an established patient E/M visit (99211-99215). The only exception is if the physician must contact another individual (such as a spouse, parent, child, or other family member) to secure background information to assist in diagnosis and treatment planning, according to the Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 70.1 (www.cms.hhs.gov/manuals/downloads/ncd103c1_Part1.pdf). The patient must be unable to provide the information himself. In this case, you may be able to report a low-level visit, but expect Medicare to reject the claim unless your documentation is especially clear as to the reason that contact with the family member was necessary.

Above all, to qualify as a payable service, the consult must focus on the Medicare beneficiarys treatment. A meeting with the family to explain the patients condition is not payable, but a meeting to determine a family members fitness to assist the patient to manage an illness may qualify (with proper documentation).

Pitfall: Although 90887 (Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient) seems ideal to report a family consult, Medicare bundles the code into other E/M services. Therefore, you cannot report it separately and expect payment.

If you are counseling the family and the patient together and the patient has presence of mind to understand what is being said, you can charge the E/M visit based on time when the time spent on counseling is 50 percent or more of the total visit time.

Important: The key is that the patient has to be there and be an active participant in the service, not a mindless presence. He has to understand what is going on.

Your surgeons documentation should state the total time of the visit, the time spent on counseling, who was present, what was discussed for the counseling, and if there is family present. You may also want to suggest that your physician document the depth of the patients participation so that the physician does not get accused of providing non-face-to-face service. Medicare does not pay for counseling a patient who will not or does not understand the counseling, so the patients understanding needs to be made clear in the note.