Billing for office visit without the patient present

[kfreschlin]

Hello everyone-my two fellow coders and I are trying to come to a consensus about whether it is allowable for a provider to bill out for an office visit when there is discussion with family members only, patient is not present. We have a pediatric practice that is billing out time-based office visits for discussions with parents and teachers. If a 99215 is not appropriate, what code would be?

 

[jkyles]

Hi there, the CPT guidelines state in part

When time is used for reporting E/M services codes, the time defined in the service descriptors is used for selecting the appropriate level of services. The E/M services for which these guidelines apply require a face-to-face encounter with the physician or other qualified health care professional.

Even though non-face-to-face work can be counted toward office visits billed based on time, there has to be an encounter between the patient and the practitioner.

 

[thranowski]

Hello everyone-my two fellow coders and I are trying to come to a consensus about whether it is allowable for a provider to bill out for an office visit when there is discussion with family members only, patient is not present. We have a pediatric practice that is billing out time-based office visits for discussions with parents and teachers. If a 99215 is not appropriate, what code would be?

I am also in pediatrics and we always have the child present, even if they just have to sit in the lobby, or for telehealth just make a brief appearance. We do not allow visits without the child present unless the parents sign an ABN and pay cash.

If the discussions with the parents and teachers are just for counseling and coordination of care, billing for care coordination would be more appropriate. (ex 99490) However, most private insurances don't pay this IME.

 

[rchehey]

So even if it is the guardian/guarantor (parent) that is present, as the one that makes all of the decisions for the child as it is..... the child would still need to be a part of the visit to be considered face-to-face for an E/M?
And if they weren't present, then it would have to be billed as a counseling code for the person present, and I would then assume one of the ICD-10 code would have to be Z71.0 encounter for medical on behalf of another?

 

[thranowski]

So even if it is the guardian/guarantor (parent) that is present, as the one that makes all of the decisions for the child as it is..... the child would still need to be a part of the visit to be considered face-to-face for an E/M?
And if they weren't present, then it would have to be billed as a counseling code for the person present, and I would then assume one of the ICD-10 code would have to be Z71.0 encounter for medical on behalf of another?

Based on the old definitions, it seems to me at least like it was allowed to not have the patient present because an exam was not necessary. You only needed 2 out of 3 elements and it said "typically x minutes are spent face-to-face with patient and/or family." However, with these new definitions, it specifically says face-to-face time is required with the patient. Therefore, in 2021, if the patient is not present, I would code based on MDM since there is no requirement of an exam and an independent historian is allowed.

With that being said, I still would not code an e&m visit based on the original post because that to me really doesn't seem like evaluation and management. It seems like coordination of care and counseling. There might be more information we're missing, so I can't say 100%.

I just know in our office, we have always discouraged visits without the patient present just because we don't want to fall into any issues with insurance since individually they can vary greatly on what they allow. Very rarely do we allow it, and usually it was only because the parent just showed up without the patient without us knowing they were going to do that.

 

[SSThomas03]

Is the service billable if the Power of Attorney was present at the encounter but the patient, who has a genetic disorder, was not due to past emotional trauma with medial treatment?

 

[jkyles]

Is the service billable if the Power of Attorney was present at the encounter but the patient, who has a genetic disorder, was not due to past emotional trauma with medial treatment?

I don't see any exceptions to the in-person requirement for an E/M visit.

 

[daphneb0226]

I have to add, that in the AMA CPT 2022 Professional Edition, page 12, number 3, under the Select the Appropriate Level of E/M Services Based on the Following paragraph, it clearly states;
"When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/OR family then TIME shall be considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (eg, foster parents, person acting in loco parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record."
So, with that guideline, I feel that it would be appropriate to bill an office visit level of E/M. As long as the documentation supports it of course.

 

[jkyles]

The 50% counseling/coordination of care guideline does not apply to office/other outpatient visits. It is one activity that counts toward a time-based o/o visit but it still has to be on the same daty as a face-to-face visit.