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Parent Consulting on behalf of child??

  1. #1
    Question Parent Consulting on behalf of child??
    Medical Coding Books
    We had a mother come in the consult with the family doctor about her son's ct results. The son has downs and is 31. The doctor dictation that he spend 30 mins discussing all the results and this and that. The office visit was billed under the mother with a dx code of V65.19 and it went to Mcare, however, Mcare denied it and then it was billed to the pt. Mother is calling now, since she got the bill and stated that it should have been billed under her son, (her son was not there) Does anyone have any thoughts on this and if it was billed correctly. To me it was!
    Thanks Alot!
    Miranda H.

  2. #2
    Location
    North Carolina
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    Medicare requires that E/M services include face-to-face services with the patient.

    It's possible that the mother's health plan may cover the service. If not...It would be billable to her.

  3. Default
    I'm new to coding (but not health care) and haven't touched on Medicare regulations during my schooling yet, but it would make sense (to me) that the charges are put on the son's account since he is the patient and the one who had the CT performed and all the documentation (eg: CT report, medical record notes regarding the physician discussing the results with the mother) is under the son's name as well.

    Surely there are particular incidences where Medicare would pay for services that were not "face to face" with the patient, as in this incidence?

  4. #4
    Location
    North Carolina
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    http://www.cms.hhs.gov/MLNProducts/d...serv_guide.pdf

    Page 7-refer to the descriptions of each level (Eval and Mgmt Service Guide)

    A Definition of New Patient for Selection of E/M Visit Code
    Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient

    http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf



    http://www.aafp.org/fpm/20060600/coding.html

    Counseling when the patient is not present

    Q How should I bill for a family conference regarding end-of-life issues when the patient is not present?

    Do you have a coding or documentation question?

    A This depends on the payer. CPT defines the counseling component of an E/M service as a discussion with a patient and/or family concerning one of several areas described in the definition. One of the areas is prognosis, and another is risks and benefits of management options. However, Medicare and some other payers require that E/M services include face-to-face services with the patient. Contact your payers to determine how best to bill for these services. If the patient's health plan won't reimburse you for the services, the family member's health plan might. If you bill the counseling service to the family member's insurer, consider using diagnosis code V61.49, "Other health problems within family," and an E/M code based on the documented time spent counseling.

  5. Default
    Nice work Rebecca. I like V61.49

  6. #6
    Location
    Milwaukee WI
    Posts
    4,466
    Default Patient unable to participate
    First off, to answer the question of who is the patient .. it's the son (not the mother).

    Next .. I do not normally deal with Medicare as we are a pediatric practice. Don't know if the patient (the son w/ Down's) is on medicare or some other insurance.

    That being said ...

    I have coded such scenarios (counseling/coordination with the parent w/o child present) when:
    1) total time is documented
    2) time spent in counseling/coordination is documented (must be >50% of total)
    3) Substance of the counseling/coordination is documented
    4) Medically necessary reason why patient is unable to participate

    In these cases, the legal medical-decision maker "stands in" for the patient.

    Pay attention to number 4) above. Not bringing the child into the office because you didn't want to take him out of school is not a legitimate medical reason.

    The bill would be filed with the patient's (son) insurance carrier.
    This would be correct coding, but the carrier may NOT pay.

    F Tessa Bartels, CPC, CEMC

  7. #7
    Location
    North Carolina
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    3,126
    Default
    The original post states the carrier was Medicare and that the patient wasn't present...how do you bill this under the son without face to face???

  8. #8
    Location
    Milwaukee WI
    Posts
    4,466
    Default Mother's carrier is Mcare
    Rebecca ... Maybe I misinterpreted, but the way I read the original post is that mother's carrier is MCare (because they billed under Mom's name)... don't know if son's is or is not.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 03-06-2009 at 05:37 PM.

  9. #9
    Location
    North Carolina
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    "The office visit was billed under the mother with a dx code of V65.19 and it went to Mcare, however, Mcare denied it and then it was billed to the pt"

    Hmmm...maybe not.

    Maybe Puggles can clarify *at least for me*

    I tend to think that someone (son) with this type of disability is normally on Medicare. His age is also a factor for me. So, I still tend to think that the providers office filed this correctly since the patient wasn't present (under the mother).

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