EM billing on time- inpatient


Best answers
I know Medicare requires patient presence to bill for a visit, but I have a question about a not so uncommon scenario in palliative/terminal care where a consult has been requested:

The provider had a 10 minute F2F with patient in the hemodialysis unit and performs a physical exam/assessment. The patient is unable to participate verbally due to mental/physical status, and the family is making medical decisions regarding treatment. Because there is not enough room in the HD unit, a family meeting takes place with the provider down the hall on the HD unit. There is an extensive discussion regarding goals of care, prognosis, trmt options, education, etc provided so that the family can decide what to do next. This meeting takes about 90 minutes. The provider documents the content of this counseling and that it dominated more than 50% of the visit.

Since the provider performed a F2F service the same day, even though the counseling was unable to be provided in presence of patient (who wouldn't be cognizant anyway), can we still combine the 10 + 90 minutes total inpatient floor time to bill the highest level (99223). We are second guessing this one, since 99.9% of the time the counseling takes place in the presence of the patient whether they are awake/cognizant or not.
I would consider this unit/floor time because all of this counseling and work essentially occurs at the unit. I believe this should count also because important portions of the history were taken from the family since the patient is non-verbal and non-responsive. I think it would be appropriate to code the 99223.
Must be at bedside for Medicare

Sorry to be the bearer of bad news ...
If this is a MediCARE patient ... you can only count face-to-face, i.e. at the bedside, time. Medicare does not recognized floor/unit time.

If the patient is covered by commercial insurance you may count floor/unit time.

Hope that helps.

F Tessa Bartels, CPC, CEMC
Are you talking about using prolonged services? I know Medicare does not follow CPT guidelines on allowing total floor time for prolonged, and we can only count F2F for those. But I just want to make sure: my question only hinges on code level for time-based billing. We aren't using prolonged services codes. This is from an AAFP article:
Third-party payers, including Medicare, may have different guidelines than CPT suggests. For example, Medicare guidelines require that the patient be present for any E/M service that is reported for payment. Thus, when time-based coding is applied in the outpatient setting for Medicare-covered visits, the patient must be present for any counseling activities. In the inpatient setting, Medicare does cover time spent on the unit or floor in discussion with family members as long as the physician has provided a face-to-face service to the patient on that day.

I'm really talking about the fact that the counseling was provided on the floor but not in presence of the patient (but there was a F2F exam/visit) due to space issues.