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Thread: Billing E/M if patient is not present

  1. #1

    Default Billing E/M if patient is not present

    AAPC: Back to School
    For example: An elderly patient has alzheimers and is cared for by their adult child. The adult child caretaker requests a consultation with the doctor to discuss the patients care. According to the 2011 guidelines, can we bill an E/M code based on time if the patient is not present? Would it be billed to the patients insurance carrier?

    I'm referring to the guideline that reads "When counseling and/or coordination of care dominates (takes up more than 50 percent of)the physician/patient and/or family encounter, then time shall be considered the key or controlling factor to qualify for a particular level of E/M. This includes time spent with parties responsible for the care of the patient or decision making whether or not they are family members"... etc...

    My key question is can you bill a patients insurance if the patient is not actually present?


  2. #2
    Join Date
    Apr 2007
    Evansville Indiana

    Default Patient not present

    If it is Medicare, no.

  3. #3


    Because Medicare doesn't necessarily follow CPT guidelines, Medicare has created their own guideline for this situation; the doctor, or NPP, must be the one to initiate the consult with the patient's family member or caregiver and the visit must be regarding education of how to care for the patient. Other carriers are going to vary, and it's best to contact provider representatives directly for correct information.

    I would also ask the family member/caregiver for his/her insurance information (prior to the visit) and contact their insurance to find out if they would cover an appointment for their own counseling in dealing with/caring for an ill family member.

    Hope this helps,


  4. #4
    Join Date
    Apr 2007
    North Carolina


    Below is the link that Kris was referring to...

    70.1 - Consultations With a Beneficiary’s Family and Associates
    (Rev. 1, 10-03-03)
    CIM 35-14


  5. #5


    Thanks, Rebecca, for putting in the link

  6. #6


    That's very helpful. Thanks!!

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