E/M without a face to face with patient

Candice_Fenildo

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I am wondering if we could charge this out as an E/M?

Pt was unable to come to appt. she is 10 years old. Mom came instead and Dr reviewed pts Catscans and bloodwork, and s/w mom about pts options for surgical intervention. Spent 30 minutes with Mom? But never physically seen the patient.
 

dmaec

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ohh.. mom's not going to be happy about this - but no, you can't. It's going to have to be billed under the MOM's name (not the child). Probably won't be covered because it's going to be an E/M level with a "V-code" dx.
 

scorrado

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I believe you can bill and E/M under the child. If you look at the CPT book and look at one of the established visit codes it states that it can be a family member. I am at home and do not have a CPT book in front of me but I am positive that they word it in such a way that the patient does not have to present for an established visit E/M code.
 

jciriello

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I am wondering if we could charge this out as an E/M?

Pt was unable to come to appt. she is 10 years old. Mom came instead and Dr reviewed pts Catscans and bloodwork, and s/w mom about pts options for surgical intervention. Spent 30 minutes with Mom? But never physically seen the patient.
Candy...At the very least you should be able to do an Unlisted E/M Service 99499. This is clearly E/M for the childs condition and if you look thoroughly in your CPT book you will find something to use. The E/M Guidelines discuss the Unlisted Service and the Special Report that will need to be submitted with it. "An unlisted service or one that is unusual, variable, or new may require a special report demonstrating the medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent and need for the ....service". As one of my teachers always said "Read your Guidelines".
Donna, you should be careful before you answer.
 

aguelfi

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I completely agree w/ jreiner. And to boot. No, you don't bill under the mother. The child is the pt, therefore you bill under the child.
 

dmaec

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I believe you can bill and E/M under the child. If you look at the CPT book and look at one of the established visit codes it states that it can be a family member. I am at home and do not have a CPT book in front of me but I am positive that they word it in such a way that the patient does not have to present for an established visit E/M code.
Suzie - I do see that. (thanks for pointing that back out to me). So, I could be wrong and you might be able to bill it under the child name, (but I'm still not convinced that's what the info under the est visit means) anyway -the code you'd be using is going to be a V-code, probably V65.1.
It might different with parents on behalf of kids - I do know that at my other facility, for our elderly patients, we could not bill Medicare if the patient was present and family members were being seen on behalf of the patient.
 
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dmaec

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Candy...At the very least you should be able to do an Unlisted E/M Service 99499. This is clearly E/M for the childs condition and if you look thoroughly in your CPT book you will find something to use. The E/M Guidelines discuss the Unlisted Service and the Special Report that will need to be submitted with it. "An unlisted service or one that is unusual, variable, or new may require a special report demonstrating the medical appropriateness of the service. Pertinent information should include an adequate definition or description of the nature, extent and need for the ....service". As one of my teachers always said "Read your Guidelines".
Donna, you should be careful before you answer.
jreiner - yes, I should be more careful with my response - thankfully - our answers in these forums are "opnions", usually based on our own experience. Nothing written in stone, if you know what I mean! .. It's why we all get to respond, and opinions "very" which you can see in ALL the forum posts. We learn something knew everyday...we're reminded of things we may have forgotten when somebody else with a bit more knowledge in an area chimes in with their VERY welcomed and appreciated information. My answer was based on my experience. I can say, that at the other facility I worked at, we didn't/couldn't bill a patient for services rendered not to them. It appears I may be mistaken and this service can be billed under the childs name although I'm still not certain I'm wrong on this- it's still going to have a Vcode for the dx - who knows what insurance will do with that.

Just reading on another forum, same issue - and oddly - same answer from another coder - seems she feels the patient needs to be present in order to charge and E/M visit also - guess it's worth checking into more if needed
 
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dmaec

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Donna, Someone else told me that as well. I just wanted to get more opinions. Not to sure on what V code to use, I'll have to do some research. Thank you for your imput

Candyr - I'm going to research a bit more also :) I'm still not convinced, but I've been wrong before! ;) I think the V code is going to have to be V65.1, what do you think about that code?
 

Lisa Bledsoe

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I'm going to step up with my "opinion" and say that I would not code an E/M visit if the patient was not present. Even though CPT E/M guidelines do not specifically state "patient must be present" it is my opinion that E/M codes are to be reported when the patient is present. I think perhaps we all need a little more guidance from CPT on this. Interesting that this does not come up in the E/M specialty study guide...
 

LEE ANN

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Wow - I would be interested to see what CPT says as well. We have this occur in our practice quite often. We normally bill under the person who is here with V codes for dx. Now I want to know if it's right!
 

dmaec

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I agree with Lisa - (and yes, more guidance would be great!)
and, same here LEE ANN - that's they we've done it for years now!
 

Herbie Lorona

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Reading in the CPT book it does state "For coding purposes, face-to-face time for these services (Talking about E&M) is defined as only that time that the physician spends face-to-face with the patient and/or family. This includes the time in which the physician performs such tasks as obtaining a history, performing an examination, and counseling the patient."
 

dmaec

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**this just in** Well, from I meeting I just attended .... ;)
for E/M charges counseling & coordination of care:
Although CPT states "patient and/or family", CMS requires patient to be present.

this info can be found on the CMS website :)

Soooo, Lisa - LEE ANN - we're doing ok!
 

Lisa Bledsoe

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**this just in** Well, from I meeting I just attended .... ;)
for E/M charges counseling & coordination of care:
Although CPT states "patient and/or family", CMS requires patient to be present.

this info can be found on the CMS website :)

Soooo, Lisa - LEE ANN - we're doing ok!
:eek:
 

dmaec

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Donna...No offense meant, but the answer was stated as a fact not as an opinion. Sorry if your feelings were hurt.
jreiner - none taken! but I don't know why there would have been anyways! no feelings were hurt...quite the contrary - I value others opinions (or facts if that what you wish). I make a conscious effort to learn from my mistakes (and I do make mistakes!), and to learn from others. I simply researched a bit more on this issue, found that I'm ok in the way we've been handling these circumstances and shared the information with everyone who responded to the original post. I will say however, that I stay far and clear away from unlisted procedure codes - never have used them for any E/M - have used them on some surgery procedures and of course have the documentation to back it up. I might add also that using the unlisted E/M code might be ok, I feel using the V-code on an E/M code under the person who is actually talking to the provider is more appropriate because there "is" an E/M visit and there "is" a dx for it. Either way, (yours or mine) chances are it won't be paid by insurance and will end up "self-pay" office visits. What is the charge for a 99499? (I ask, because I have no idea)
 

CindyNorling

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Patient not Present - billing based on time

My opinion comes from the CPT manual under the Evaluation and Management (E/M) Services Guidelines very last page.

I know Medicare has a policy that they will not pay for a visit if the patient is not present – but CPT states when billing an E/M service based on time:

“When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may 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.”

Claim would be submitted under the child. Naturally all appropriate documentation for billing based on time must be in the medical record.

Also in the description for CPT codes 99201-99215 reads such as on 99213 "Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

Some payers may have a policy such as Medicare when patient is not present.
 

Jhart

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Although CPT does not specifically state the patient has to be present, it does consider the examination to be a key element of the E&M. Without a face to face with the patient, there can't be an examination.
 

Jhart

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That information is located in the information when time is considered as part of determining the level of E&M code. You still have to have an examination to have an E&M visit.
 
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Counselling/coordination of care

When billing based on time for counseling/coordination of care, you do NOT need to meet the levels of history, exam or MDM to choose a level of E/M.
No exam is required. The entire visit can be counseling/coordination of care, and if properly documented and E/M service can be reported.

Cindy Norling is correct
F Tessa Bartels, CPC, CPC-E/M
 

Treetoad

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I believe it's a Medicare requirement for the "face to face" encounter with the patient. Some other carriers might pay the claim according to CPT requirements. It would be best to check with the carrier.
 
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