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ksobota

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Doctor had 30+ minute audio call with patient family during pandemic. They did not want to tell patient about this visit b/c patient is an alcoholic that has had a CVA and is becoming more belligerent and hard to for them to deal with. Wanted to speak with patient's physician regarding best/possible steps moving forward to get help for patient. Patient has Medicare.

Our doc wants to bill
99358
Prolonged evaluation and management service before and/or after direct patient care
which allows for non face to face contact.

My problem is billing patient's insurance with no prior approval from patient. I don't feel you can bill a patient's insurance for a visit with their family that they were unaware of. Problem is I need something to show the physicians. I think this should be billed out from the office to the family directly as a fee that is covered out of pocket, but need to make sure first there's nothing I can bill out to Medicare or need something to show them. Just hoping for any help.

thank you!
 
There shouldn't have been a phone call without documented permission from the patient, or healthcare power of attorney AND the patient being unable to care for himself. Medicare is very particular about paying for services without the patient being there, although they have eased up over the last decade. For instance, the office visit E&M codes now say, "typically, xxx minutes are spent with the patient and/or family." It didn't always say "or family".

Here is a medicare document geared towards patients about this subject (click me).

Since there was no permission (unless the HPoA is in place and the CVA makes him unable to care for himself), there has been a HIPAA violation of the patient's right to privacy. I wouldn't bill the insurance OR the family for something that is a violation. However, if privacy has been waived by the patient, then the document I referenced allows it to be billed.
 
Child has POA for the patient, so HIPPA wasn't violated. It's more the problem with Medicare and patient presence I was worried about.

Thank you for your reply! Appreciate you taking time.
 
During the NGS Medicare telehealth call yesterday, this specific type of question was asked. The response was that if the patient was not present/part of the call (or video), there are no billable services to Medicare. Even if the family member participating was the healthcare proxy or POA.
Just like pre-covid, if family members come in without the patient present, Medicare cannot be billed.
I would call this a learning experience which likely doesn't happen frequently, and consider it your good deed for the day.
 
csperoni said:
During the NGS Medicare telehealth call yesterday, this specific type of question was asked. The response was that if the patient was not present/part of the call (or video), there are no billable services to Medicare. Even if the family member participating was the healthcare proxy or POA.
Just like pre-covid, if family members come in without the patient present, Medicare cannot be billed.
I would call this a learning experience which likely doesn't happen frequently, and consider it your good deed for the day.
Click to expand...

Well, someone is crossing wires somewhere, because the document I linked is put out by Medicare, that specifically tells caregivers that it CAN be billed.
 
SharonCollachi said:
Well, someone is crossing wires somewhere, because the document I linked is put out by Medicare, that specifically tells caregivers that it CAN be billed.
Click to expand...

It's a rather poorly worded publication, but as I read it, the document says the provider may NOT bill Medicare for the time spent talking, which suggests that this time must be excluded from any time or work spent during the office visit:

During a face-to-face, medically necessary office visit, your friend or family member’s doctor can spend time talking with you about the condition and/or treatment plan, even if your friend or family member isn’t in the room. The Medicare Part B (Medical Insurance) office visit payment includes the time that the doctor spends talking with you. This means that the doctor can’t bill Medicare or your friend or family member separately for the time you talked.

My understanding of the guidance given in the Medicare Claims Processing Manual, section 30.6.1, has always been that if a provider is billing an E&M office service based on time spent counseling the family in the office, the patient must be present:

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.

However, in section 30.6.15.2, it does state that CPT codes 99358 & 99359 are now payable:

Until CY 2017, CPT codes 99358 and 99359 were not separately payable and were bundled (included for payment) under the related face-to-face E/M service code. Practitioners were not permitted to bill the patient for services described by CPT codes 99358 and 99359 since they are Medicare covered services and payment was included in the payment for other billable services.

Beginning in CY 2017, CPT codes 99358 and 99359 are separately payable under the physician fee schedule. The CPT prefatory language and reporting rules for these codes apply for Medicare billing. For example, CPT codes 99358 and 99359 cannot be reported during the same service period as complex chronic care management (CCM) services or transitional care management services. They are not reported for time spent in non-face-to-face care described by more specific codes having no upper time limit in the CPT code set.

Based on this language, I believe that 99358, to reflect the excess time spent outside of the E&M service, would be appropriate to bill in this situation assuming the documentation meets the requirements of the CPT code description.
 
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The caregiver document states during a face to face visit, the provider speaks with the caregiver alone and payment is included in the E/M service. In the scenario posted, it is not stated there was a face to face visit by the patient.
We have always been told by Medicare for outpatient services, if the family/caregiver comes in for a visit without the patient present, Medicare cannot be billed. During this week's NGS telehealth call, the question was posed if you can bill 99441-99443 for telephone calls, or 99201-99215 for video telehealth, with family members if pt does not participate/is not present. Their answer was basically you are not providing medical care if the patient is not present, therefore there is no medically necessary service and cannot be billed to Medicare. I'm not saying I agree with their policy, only relaying the information provided.
I believe you can charge the family/caregiver, but would certainly want to inform them prior and give fees. In our office, we choose not to bill the family/caregiver (it's maybe 3 times a year for patients who are very ill, possibly in hospital or hospice).
I know the CPT definition states patient and/or family regarding counseling, but Medicare does not. I go back to the Medicare claims processing manual, chapter 12, 30.6.1 C: https://www.cms.gov/files/document/medicare-claims-processing-manual-chapter-12
"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."
It's possible 99358 is appropriate, but I just don't interpret it that way when the patient is not involved. NGS Medicare clearly stated this week that it is not covered for telehealth, telephone or in person if patient is not present. Also, if 20% cost share applies, the patient is going to get a bill for services they didn't even know were being provided, and never agreed to.
I would not bill this to Medicare. For private carriers, I think it is open to interpretation.
 
I agree with you all. I think I read that document that I mentioned a bit differently the first time, and I thought Medicare had eased up on their requirements. I agree it is poorly worded.

We used to have this discussion all the time in mental health, when the family wanted to come in without the patient. One patient even said that their mother was the cause of all the patient's problems, so the mother's Medicare should be billed. When I declined, I got the "but all the other doctors do it." My standard response to that was always, "well, if you would like to file a fraud complaint against all the other doctors, I can help you with that."
 
This is great information. I have a question about provider based telehealth services. We are an outpatient department of a facility and we use provider based coding where we get to assign a facility charge and a professional charge. Does anyone know if we can charge a facility fee for telehealth? Our nurses are asking the same questions and reviewing the same information with a patient that they would see in the office, but they do not check vitals.
 
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