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Family Meeting CPT Code

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Billing when Medicare Patient is not present

The thread you referenced is in line with everything I have always heard and is the guidance I have always given. However, recently I was directed to section 70.1 of the Medicare National Coverage Determinations Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_Part1.pdf

I included the source for ease of verifying, but here is the language that contradicts what I have always understood:

70.1 - Consultations With a Beneficiary’s Family and Associates
(Rev. 1, 10-03-03)
CIM 35-14
In certain types of medical conditions, including when a patient is withdrawn and
uncommunicative due to a mental disorder or comatose, the physician may contact relatives and close associates to secure background information to assist in diagnosis and treatment planning. When a physician contacts his patient’s relatives or associates for this purpose, expenses of such interviews are properly chargeable as physician’s services to the patient on whose behalf the information was secured. If the beneficiary is not an inpatient of a hospital, Part B reimbursement for such an interview is subject to the special limitation on payments for physicians’ services in connection with mental, psychoneurotic, and personality disorders.
A physician may also have contacts with a patient’s family and associates for purposes other than securing background information. In some cases, the physician will provide counseling to members of the household. Family counseling services are covered only where the primary purpose of such counseling is the treatment of the patient’s condition.
For example, two situations where family counseling services would be appropriate are as follows: (1) where there is a need to observe the patient’s interaction with family members; and/or (2) where there is a need to assess the capability of and assist the family members in aiding in the management of the patient. Counseling principally concerned with the effects of the patient’s condition on the individual being interviewed would not be reimbursable as part of the physician’s personal services to the patient. While to a limited degree, the counseling described in the second situation may be used to modify the behavior of the family members, such services nevertheless are covered because they relate primarily to the management of the patient’s problems and not to the treatment of the family member’s problems.
Cross-references:
The Medicare Benefit Policy Manual, Chapter 6, “Hospital Services Covered Under Part B,”§20.
The Medicare Claims Processing Manual, Chapter 12, “Physician/Practitioner Billing,” §10.
The Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, “Deductibles, Coinsurance Amounts, and Payment Limitations,” §30.



Additionally here is an article from ACP internist that contradicts that standard answer: "you can never bill Medicare when the patient is not present." http://www.acpinternist.org/archives/2008/11/coding.htm

Specifically, I'd be interested in how do you bill prolonged services in additional to a subsequent Hospital visit for an inpatient? For Medicare it is okay to use Unit floor time as far as non-face to face time with the patient for the E&M, but Medicare differentiates from AMA on the prolonged codes and you must use the "patient not present prolonged codes" for unit floor time when the patient is not present for a prolonged service (although the AMA would allow unit floor time situation with the family as a "prolonged with patient present" because it was unit floor time devoted to the patient. The other issue, would be the outpatient or office POS. Per section 70.1 of the National Coverage Determinations manual, a Physician MAY be able to bill in the clinic setting for a family conference depending on the nature of the counseling. Please share your thoughts regartding Medicare and patient not present. Have coders drawn too hard of a line as far as the "you can never bill Medicare when the patient is not present." Should we have been saying "You can never bill Medicare when a patient is not present, unless you meet the criteria in section 70.1 of the Medicare National Coverage Determinations Manual?

I would love to hear people's thoughts on this.

Regards,

Mark
 
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