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kitkat_46510

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One of my clinicians documented an appointment with a patient's PARENTS (patient is a minor) yesterday. The pateint was NOT present. Can this still be classified as an E/M visit without patient present. I cannot seem to find the answer anywhere else.:confused:
 
Was this family psychotherapy without the patient present? (90846)
OR was this a biopsychosocial assessment/intervention? For example- Health and Behavior intervention, each 15 minutes, face-to-face w/ family (without the patient present) (96155)

You can't bill a typical office visit (99201-99215) without a patient encounter.
 
The CPT definition of an E&M service specifically includes mention of the patient and/or family:"Physicians typically spend XX minutes face-to-face with the patient and/or family.
"When discussing how to use time to select a code in the introductory section for E&M services, the CPT manual says:"When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter…

"This implies that an E&M service may be provided to a family member on behalf of a patient.
Why might this be necessary? A parent may want to discuss a child’s care without the child being present. In this case, if the payer follows CPT rules, a physician could bill the encounter as a meeting with the parent. The physician would bill the service based on time, document the nature of the counseling, and describe the reason why the service did not include the patient.
For the diagnosis code, in addition to the condition being treated or discussed, you should add V65.19: "Other person consulting on behalf of another person." Using the V code may result in a denial from the payer, but correctly informs the payer that the patient was not present at the visit.

If the payer denies the service as "incidental" or "bundled," and you have a contract with that payer, you can’t bill the patient or family for the service. If the reason for the denial is "noncovered" then you can typically bill the family member who requested the service.

Hope this helps.
 
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Yes - the guidelines say that time may be considered when counseling or coordination of care dominates the encounter. Yes - The counseling can be with the patient and/or the family - but I believe the family counseling must still be done in the context of a patient encounter. For example, you spend some time evaluating the patient who is unconcious or somnolent, then spend some time discussing the prognosis or plan of care with the family in the next room. That time may be counted. The provider isn't limited because the patient is unconscious and not able to participate in the counseling - it is medically necessary (for the patient's care) to have that discussion with the family.

I don't believe you are correct in your assumption that you can bill a child for an office visit for counseling the family without the patient even presenting to the office. Think of the implications -- you think Dr. Jones should bill the daughter even though the she wasn't there, and the encounter was just to counsel the mother? What if the parents are divorced, and the father gets the bill for the copay? The daughter says she never had an office visit that day... the father finds out that he is paying a bill for a service that was essentially done just for the mother. Since the claim went out under the daughter's name, that is potentially a false claim.

What would be the medical necessity for the encounter with the mother? Why wouldn't that just be a phone call?

I would be very careful about the advice you are giving.
 
MikeEnos said:
Yes - the guidelines say that time may be considered when counseling or coordination of care dominates the encounter. Yes - The counseling can be with the patient and/or the family - but I believe the family counseling must still be done in the context of a patient encounter. For example, you spend some time evaluating the patient who is unconcious or somnolent, then spend some time discussing the prognosis or plan of care with the family in the next room. That time may be counted. The provider isn't limited because the patient is unconscious and not able to participate in the counseling - it is medically necessary (for the patient's care) to have that discussion with the family.

I don't believe you are correct in your assumption that you can bill a child for an office visit for counseling the family without the patient even presenting to the office. Think of the implications -- you think Dr. Jones should bill the daughter even though the she wasn't there, and the encounter was just to counsel the mother? What if the parents are divorced, and the father gets the bill for the copay? The daughter says she never had an office visit that day... the father finds out that he is paying a bill for a service that was essentially done just for the mother. Since the claim went out under the daughter's name, that is potentially a false claim.

What would be the medical necessity for the encounter with the mother? Why wouldn't that just be a phone call?

I would be very careful about the advice you are giving.
Click to expand...

If a pregnant women meets with a pediatric orthopedist because her unborn baby may have clubfeet - can you bill the mother's insurance for counseling & coordination of care based on time?
 
I would imagine so, the only alternatives would be to bill a fetus or not bill at all. Seems like legitimate medically necessary counseling.
 
Coding by time was intended, I believe, to give credit for the EXTRA time spent counseling a patient and/or family member. I don't believe you can fail to meet the other elements of the E/M service in lieu of time spent counseling.
 
Face-to-face without patient

I found this information on a Medicare MAC websites:

Q13. We met with the family of a pediatric patient to provide counseling/coordination of care and did not see the patient. Can we bill this visit to Medicare under the pediatric patient's Medicare number? Is this considered family counseling and therefore billed under the mental health services?

A13. Counseling/coordination of care is face-to-face time with the patient. (Reference: CMS IOM Publication 100-04, Chapter 12Adobe Portable Document Format, Section 30.6.1.C) Medicare can allow a charge for time spent with the family in only two situations:

1. The physician is asking the family for history or discussing the options for the patient’s care when the patient is incapable of participating

2. The services would fall under the mental health counseling provision of Medicare.
(Reference: IOM Publication 100-03, Chapter 1, Section 70.1.Adobe Portable Document Format )
 
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AMA E/M guidelines:
The CPT definition of an E&M service specifically includes mention of the patient and/or family:"Physicians typically spend XX minutes face-to-face with the patient and/or family.

Medicare (which does not follow the AMA E/M guidelines) requires a face to face.
The question posed does not state the child has Medicare.

I can think of 100 scenarios why a pediatrician or parent would not ant a child present when discussing a diagnosis.
Advise your clients to leave money on the table if you wish.
 
Oceanlivin said:
AMA E/M guidelines:
The CPT definition of an E&M service specifically includes mention of the patient and/or family:"Physicians typically spend XX minutes face-to-face with the patient and/or family.

Medicare (which does not follow the AMA E/M guidelines) requires a face to face.
The question posed does not state the child has Medicare.

I can think of 100 scenarios why a pediatrician or parent would not ant a child present when discussing a diagnosis.
Advise your clients to leave money on the table if you wish.
Click to expand...

You must know that the CPT definitions for E/M services are not very specific, so most insurances defer to CMS when calculating level of history, exam, medical decision making, and other E/M nuances that are not well-defined by CPT. I'm sure you could think of 100 scenarios, as could I, but I'm focusing on the scenario in the original post.

I have yet to see anything to suggest it would be appropriate to bill a patient for an E/M service for which they were not present. I already explained why I feel like the excerpt you are relying on is being misinterpreted. Here is a quote from the Medicare Claims Processing Manual Chapter 12 Section 30.6.1 Part C - "Selection of Level of Evaluation and Management Service Based on Duration of Coordination Of Care and/or Counseling"

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. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service.
Click to expand...

This confirms that if you are selecting the level of service based on time spent counseling or coordinating care in the office setting, the patient must be present - even if you are counseling the family. I really cannot recommend billing an E/M service for a patient who was not present.

For more information, here is a helpful article on the Santa Clara County Medical Association website titled "Family Conferences: Whether to bill, and when?"
 
littleone said:
I would think that the pregnant patient would be able to get a consultation from ortho with a congenital anomalies code for the Dx.
Click to expand...

No you cannot use a congenital code for a pregnant patient to indicate a fetal condition. You can use a congetital code only for the patient with that condition. A pregnant patient must be coded with a pregnancy dx code, you can use one that indicates a fetal abnormality.
 
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