Neurology & Pain Management Coding Alert

Question: Is there any way we can charge for a visit to discuss a patient's situation if the patient isn't present? The CPT descriptors for established patient E/M codes do specify, "the physician typically spends X minutes face-to-face with the patient and/or family" [emphasis added].


Nevada Subscriber
Answer: Regardless of the phrasing in CPT, most insurers, including Medicare, will not reimburse for any E/M service - even if those strictly concerned with counseling or coordination of care - if the patient is not present. Simply put, without face-to-face time with the patient, you haven't got a billable service.

The only exceptions are:

1. 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 Carriers Manual, section 35-14. This would require that the patient be unable to provide the information himself. If this is the 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. 

2. The neurologist must meet with the family member because the patient is incompetent or otherwise unable to make care decisions for himself.
 
If the family simply wishes to discuss the patient's condition with the physician - and the service does not meet any of the two conditions mentioned above - you can choose either to offer the visit as a courtesy or to render the service on a fee-for-service basis. To protect your reimbursement in the latter case, you should designate someone within the family to sign an advance beneficiary notice.