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Billing E/M if patient is not present

  1. Default Billing E/M if patient is not present
    Medical Coding Books
    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
    Evansville Indiana
    Default Patient not present
    If it is Medicare, no.

  3. Default
    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
    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
    Rebecca CPC, CPMA, CEMC

    Your click COUNTS...

    CLICK to give FREE mammograms!

  5. Default
    Thanks, Rebecca, for putting in the link

  6. Default
    That's very helpful. Thanks!!

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