How to code E&M in office if patient not present?


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I need help on how to code an E&M in the office if the patient is not actually present. This is a first for me. Can we bill an established pt office visit in the 9921_ range? Here is the note by the doctor:

HISTORY OF PRESENT ILLNESS: This patient is a 9-year-old African American female who presented to our clinic with lower back pain. Initially, her mother complained also of pain in her proximal thigh. Presumably she has suffered a push-and-fall trauma while at school, and has experienced mid-thoracic back pain since that particular point in time. She does have an ANA of 1:640, elevated CPK, elevated rheumatoid factor, and elevated sed rate. We repeated labs, for the most part, and placed her on Celebrex 1-daily. She did not present for clinic today, but her mother came seeking her labs.

LABORATORY DATA: Normal CBC with no reactive thrombocytosis. Sed rate normal, CRP normal, CPK completely normal. C-reactive protein 2.4, negative.

IMPRESSION: Essentially normal labs. The labs were reported to the patient's mother.

PLAN: In the interim of time, she has noted no additional complaints, so we will continue following her on an as-needed basis. We would recommend seeing her in approximately six months for reassessment and follow-up.
I don't think there is one. I don't really think that it is a billable service, since the md did not examine the patient and could have relayed lab results via phone, but you may be able to code it as unlisted.
You might want to look at 99358 in the CPT book, not sure if you'll be able to use it but take a look at it. Have you thought about billing the family directly? We have billed the family for a "family visit" to discuss the patients prognosis, therapies etc.... we came up with a charge based on the "time" of the visits for example if the physician spent 35 minutes with the family we would charge them equavalent to a level 4 ov.

Keep in mind that our office has put this into the doctors office schedule and the families are made aware of this prior to making the appt, we always give the family the option of the physician calling them but some want that face to face time with the doctor.

Hope this helps.


I'd say that, since this is an established patient, and there is history and medical decision making to bolster using a 99211-99215 CPT that you could use them. To further that argument: CPT states "physician typically spends X minutes face-to-face with patient and/or family. I'd say this qualifies based on the 'or family' inclusion.

However, if you are uncomfortable with it, you could bill 99499 Unlisted Evaluation and Management and submit the claim 'by report' (with an attachment of the record) and hash it out with the payer.
Good luck!

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I don't think that an E/M code can be used if the patient is not physically present/examined. The 3 main components in selecting a level of service require that a focused hx be done, an exam, and ultimately a decision/diagnosis made. I don't believe these can be done w/out the patient present. The "counseling and coordination..." mentioned in the code descriptions take part after these key components are made.

Also, 99358 is an add-on code and would thereby require the use of an E/M code in order to be used. As for the unlisted E/M, I don't think it would be applicable because it still falls under the category of a professional service, which cpt defines as "fact-to-face services" and, again, since your patient is not present I don't think the code would fit. I looked through the Medicine section but couldn't find anything in there either - sorry! Good Luck to you!
"See the following link from AAP:

At the bottom, they explain that the family member may be seen without the patient and the provider may code when time is properly documented."

I would be careful in coding visits when the patient is not present. If you read past this statement found in the link above, AAP also states that, "It is important to note that some payers, including Medicare and some state Medicaid plans, require that the patient be present. Always check with your payers as their policy may differ from CPT guidelines."