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How to bill when patient not present

  1. #1
    Default How to bill when patient not present
    Medical Coding Books
    I have read some other posts and haven't found an answer to this question so far. Here is the scenario that I am encountering:

    I work with a group of internal medicine doctors who use hospitalists for their patients.

    Medicare patient who is an inpatient in the hospital. Patients family comes to our office for an appt with the patients doctor (patient not present) for clarrification on patients hospital course, condition, diagnosis, etc because they feel they are not getting adequate information and/or clarrification from the hospitalist. Our doctor reviews patients hospital records and discusses treatment, prognosis, and options with the patients family.

    How can I bill for this??
    1. Can I bill to insurance, or do I bill patient family personally?
    2. What codes do I use?

  2. #2
    Central Pittsburgh
    In order to bill an E/M service there MUST be a face-to-face encounter between the patient and the MD. There are codes available for care conferences with or without the patient/family. However, it doesn't appear to be the case in your situation.

    If you have policy in place, you could charge the family.

    Sorry I couldn't provide more information.

    Suzan Berman CPC, CEMC, CEDC

  3. #3
    You can not bill Medicare if the patient is not present.

    As far as setting up a fee for speaking with the family regarding the patients condition, treatment, etc I don't see any reason why you couldn't but since you didn't have this in place before the visit I don't see how you could go back and do that now.

    I don't know how often your provider does this, if it happens a lot there is something wrong with the services provided by the hospitialists in my opinion. I would want to address that instead of having to re-do their work.

    If this happens very infrequently, I would just chalk it up to good patient care and not charge for it.

    Just my take on it,

    Laura, CPC, CEMC

  4. #4
    What type of situations, if any, would you be able to bill if the patient's family came in to speak to the physician about the patient? We have other situations where the patient is unable to come, due to mobility issues related to age or disease, therefore the family comes in to discuss their care. am I overlooking where these instances could be billed to insurance? or do they always have to be billed to the family?

  5. #5
    Default prolonged visit
    If you are seeing the patient while they are in the hospital wouldn't this be a good scenerio to bill the revised prolonged visit codes? it does not have to be on the same day as and E/M service.

  6. #6
    It clearly states in the description for office visits: Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs

    Physicians typically spend ___ minutes face to face with the /B]Patients and/or family......

    Reading that description, I would think that you would be able to bill for this service even though that patient was not present. CPT code book does not state that the patient must be present.

    If anybody has documentation on this, please post?????

    Last edited by krssy70; 12-14-2009 at 01:05 PM.
    Kristen Richard, CPC

  7. Default
    I have the very same question. Just had the same situtuation come up in our office.
    Just read in the CPT within 99201-99215 regarding counseling and coordination of care..."with patient and/or family".
    I had always understood that the patient had to be present so while trying to find a code within Team Conferences I was directed to E/M when it was only the family and doc.

    Does anyone have clarification on the statement in CPT? Now I am confused!

    Debbie Cornelius, CPC

  8. #8

    I too was always under the assumption that the pt must be present. But going back and reading the CPT guidelines for the E/M office visit codes, it states pt/or family. Some providers will consider these kinds of visits, a non-billable visit. But then you have the providers that want to bill for "everything". Here some info that I found in the 1997 documentation guidelines:


    In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient/and/or family encounter (face to face time in the office or other or outpatient setting, floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.

    DG: If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face to face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordiante care.
    Kristen Richard, CPC

  9. #9
    See this thread for a related conversation..

  10. #10

    I just reveiwed your discussion in the other forum...OMG..I can't believe what I was reading. It is unfortunate that some people have to continue to argue. I think that Ltibbits said it perfectly...Happy Holidays. I hope my posting will help in your decision.
    Kristen Richard, CPC

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