Part B Insider (Multispecialty) Coding Alert
No Patient Present? Don't Expect Payment From Medicare
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CMS' face-to-face E/M billing requirement could nip payment in the bud when you meet with a patient's family
Answer: You probably cannot collect reimbursement from Medi-care for discussions with a family member about a patient's condition if the patient is not present during the session.
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 to this rule 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 Carriers Manual, section 35-14. The patient must be unable to provide the information himself for you to qualify for this circumstance.
In this case, you may be able to report a low-level visit, but expect your Medicare carrier to reject the claim -- unless your documentation is especially clear about the circumstances. The documentation must specify why that contact with the family member was necessary in your treatment of the patient.
To qualify as a payable service, the consult must focus on the Medicare beneficiary's treatment. A meeting with the family to explain the patient's condition is not payable, but a meeting to determine a family member's fitness to assist the patient to manage an illness or injury may qualify (with proper documentation).
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.
Part B Insider (Multispecialty) Coding Alert
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