Oncology & Hematology Coding Alert

Question: Can we bill family counseling if the patient is not present?

New Hampshire Subscriber  
Answer: Medicare coverage guidelines (Coverage Issues Manual 35-14) state that family counseling services are covered only when the primary purpose is to treat the patients condition. To bill Medicare, a physician can only consider the time spent counseling the patient and/or family members about patient care -- and not the course of the disease only.
 
The Medicare Carriers Manual (MCM), Section 15501, C, also addresses family counseling, specifically as it relates to selection of a level of E/M service based on coordination of care and/or counseling. The MCM states, In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. It continues, Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.
 
Private insurers might pay for a broader range of family counseling. Using CPT definitions and instructions, any counseling session with family members (including one to discuss the patients condition) can be billed as a visit based on time. Some private insurers will pay for such visits. It is always best to verify coverage policies with your local carriers.