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tscobee

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If a provider did a telehealth visit with a caregiver from an assisted living facility, can I bill an E&M or would it be considered a phone visit since it was not with the actual patient?
 
Hi there, unless you have a payer that has some sort of exception, you can't bill a telehealth (audio and visual) or telephone E/M visit if the patient wasn't present. Based on the timing and nature of the conversation you might be able to count it toward a home/residence E/M visit with the patient.
 
If it was at least 30 minutes, you could consider 99367 for medical team conference without patient or family. If not, as @jkyles advised above, this is not a telehealth or telephone E&M since the patient did not participate. CMS has expressly advised whether telehealth, telephone, or in person visits, the patient must be present to bill 99202-99215, 99441-99443. I am not aware of any other carrier that will allow those codes in this situation, but since private payors make their own rules, it is possible.
If the discussion was the same calendar day as an in-person or telehealth (audio/video) with the patient, the time is countable toward that visit with the patient, or if billing on MDM can be counted toward data category 3 discussion of management with external QHP.
 
I would review the long description of 99367 for a medical team conference, because what is you've described doesn't appear to meet the requirements for billing it. Per Encoder Pro the long description of 99367 is:

A medical team conference is defined as a service where at least three qualified health care professionals from different specialties or disciplines, each of whom provides direct care to the patient, actively engage in the evolution, revision, coordination, and implementation of health care services needed by the patient. The conferences may or may not involve the presence of the patient, family members, community agencies, surrogate decision makers/legal guardians, and/or caregivers. Medical team clinicians should report the time spent in a team conference with the patient and/or family present with the appropriate E/M code, using time as a key controlling factor for selecting a code when counseling and/or coordination of care dominates the service. The individual clinician must be directly involved with rendering face-to-face services outside of the conference visit with other clinicians or agencies. All medical professionals participating on the medical team must document their own individual participation in the team conference, in addition to their contributed information and follow-up treatment recommendations.

If your provider is the only qualified health care professional who participated in this session/appointment it doesn't meet the most basic requirement for billing 99367.
 
CBLENNIE said:
I would review the long description of 99367 for a medical team conference, because what is you've described doesn't appear to meet the requirements for billing it. Per Encoder Pro the long description of 99367 is:

A medical team conference is defined as a service where at least three qualified health care professionals from different specialties or disciplines, each of whom provides direct care to the patient, actively engage in the evolution, revision, coordination, and implementation of health care services needed by the patient. The conferences may or may not involve the presence of the patient, family members, community agencies, surrogate decision makers/legal guardians, and/or caregivers. Medical team clinicians should report the time spent in a team conference with the patient and/or family present with the appropriate E/M code, using time as a key controlling factor for selecting a code when counseling and/or coordination of care dominates the service. The individual clinician must be directly involved with rendering face-to-face services outside of the conference visit with other clinicians or agencies. All medical professionals participating on the medical team must document their own individual participation in the team conference, in addition to their contributed information and follow-up treatment recommendations.

If your provider is the only qualified health care professional who participated in this session/appointment it doesn't meet the most basic requirement for billing 99367.
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Good catch! I don't have EncoderPro, but do have Codify. Codify does not define team. States "physicians and other qualified providers of different specialties" without giving any minimum number. Interpreting my own personal experience, I would think the practice physician wouldn't need to speak for 30 minutes with a nursing assistant type of individual, but rather someone at the ALF who is making treatment plans about the patient like an NP. If the practice physician were speaking with a non QHP, I can't imagine it would need to be for 30 minutes. I think there is likely not a way to capture reimbursement for this unless the patient was also seen the same day, and was trying to come up with possible ways to do so.
 
That's kinda what I was thinking as far as not being able to be reimbursed. It's a nurse practitioner doing a televisit at a group home. She is talking to either the caregiver or a family member.
 
tscobee said:
That's kinda what I was thinking as far as not being able to be reimbursed. It's a nurse practitioner doing a televisit at a group home. She is talking to either the caregiver or a family member.
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IF you also incorporate the patient and via video, then it would be telehealth 99211-99215 (with appropriate modifier for the carrier) and your provider may count all time spent that day related to the care. If it's a one off or very rare, I would just let it go. If you have multiple ongoing patients in this scenario, you may want to evaluate how these services are provided.
 
So....circling back to this. What if a provider in the office does a phone visit to a parent/caregiver because the patient is too young or incapable of talking? Would he be able to charge the 99241-99243 codes?
 
You mentioned the physician being in the office and conducting a phone visit with a parent or caregiver but listed CPT codes that are for outpatient consult E&Ms 99241 (this code was deleted effective 01/01/23) and 99242-99243. Did you mean to ask about the telephone E&M codes 99441-99443?

If that is the case then it appears based on description of these codes in EncoderPro that the telephone E&M would be allowed with a parent, if the E&M originated from the parent (the parent contacted the office to request the telephone E&M, not the provider initiating a call to the patient/parent as the description states:

Telephone evaluation and management service originating from the established patient, parent or guardian by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; x-x minutes of medical discussion.​

So, assuming the request for the phone visit originated from the parent and the patient hasn't been seen within the previous 7 days nor does the phone visit result in an E&M or procedure within the next 24 hours or soonest available appointment, it appears that this service would be covered with a parent or guardian without the patient participating the phone E&M. However, there is no mention of this service being covered for a patient's caregiver who is not a parent or guardian, so the patient would have to participate in the call for a telephone E&M visit to be coded with the codes in the range of 99441-99443.

Also, since these are time-based codes, it is imperative that the provider document exactly how many minutes the provider spent on the call with the patient/parent in the medical record.

If you were genuinely asking about the consult codes in the range of 99242-99243, that is a whole other kettle of fish and my response would be radically different, so let me know if you did need info on trying to code for phone consults with codes 99242-99243.
 
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