Saturday, September 18, 2010

Coding/Billing Guidelines for “Family visits/Consultations”

Coding/Billing Guidelines for “Family visits/Consultations”

This came to me this week when a co-worker’s family wanted to meet with the physician regarding a plan of care for dealing with her elderly parents, and their medical, social, and basic living needs. She was shocked to find out they could not just “bill” her Mom’s medicare. So, after some discussion and research this is what I found out we can do. (as a Coder, Provider or family member)

The bottom line from all the research that I did…. is that 3rd party payors do not want to pay for medical counseling unless the benificiary is present when the provider renders this service.

When I started digging, (and numerous phone calls made) the rationale from insurance carriers…to put in layman’s terms; it’s the same as “stolen identity”. Ie… "your credit card has been stolen and is being used to purchase services the cardholder never received or authorized". This made total sense to me once explained . (I also hadn't thought about the HIPPA issues involved too)

Wow!!!!… I guess I never realized that this could be such an complex issue for coders and providers too. CMS and CPT both have rules the providers must follow but do not necessarily mirror each other especially in light of HIPPA, billing criteria, and how to code for these services.

Anyway………Here’s the info I found to share on the subject for coders, providers, medical offices and family members to ponder if you are presented with this situation… I hope this clarifies some of the issues that surround this sticky issue! and as always, feel free to contact me regarding ??'s at

Enjoy! L : )


CPT gives us some direction how to deal with this…(straight from CPT)

99201 (-02, -03, -04, -05) Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. 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. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family

So, in CPT language, this can be interpreted as

§ The provider can provide care and/or counseling and coordination of care with just the patient

§ The provider can provide care and/or counseling and coordination of care with just the family member

§ The provider can provide care and/or counseling and coordination of care with both together.

Where this gets problematic is the billing issues. These issues encompass the place of service such as Hospital, (Inpatient & Outpatient) Office and Emergency Room…So let’s clarify what we need to do:

Medicare/Medicaid for Office/Outpatient Services:

For Office/Outpatient services, CMS does not allow for payment unless the patient is present at the time the services are rendered. The rationale behind this is Medicare considers this part of the pre-post workup for an E&M service, and is a long standing Medicare Policy.

An ABN cannot be used as the patient was not there and engaged in the face-to face process. rationale: the ABN has to be acknowledged and signed by the beneficiary, which cannot be done if the patient is not in attendance.

Private Payor for Office/Outpatient Services

Again, we can default back to the CPT guidelines, but many private payors have contractual or internal policies regarding this type of service. CPT states we can use the code, but it will be up to the private payor to determine if they will pay for the service. If you plan to bill a private payor for “family counseling” here are a couple of options you can consider:

§ Bill the patient’s carrier with a paper claim, utilizing the standard E&M codes; submit the claim with documentation stating medical necessity of meeting with the family, without the patient present, be sure to use the diagnosis “V” code of V65.19: "Other person consulting on behalf of another person." (i.e. full disclosure of the nature of the visit to the carrier)

§ Schedule an appointment with the family member, as a patient in your practice, and bill his/her insurance payer for counseling coordination of care of themselves in relation to their family members medical issues (such as the stress on you as a care-giver, etcc)

§ Schedule an appointment with the provider for the family member(s) and inform the family members that for xxx amount of time, the charge is $XXX.oo. Disclose to the family members that this will need to be paid in full up front, at the time of visit. You also need to inform the family at the time of scheduling that without the patient’s consent, (or medical power of attorney) the provider/physician may not be able to disclose any information regarding the patient due to HIPPA privacy laws.

Inpatient services:

In regard to the Inpatient side of things, it works just a bit differently. The patient is currently present in the hospital, so this is much easier for the physician to communicate and coordinate care in regard to the patient with the family members. The argument of the patient not being there is irrelevant.

In some cases the patient is so critically ill, that a family member can “speak for” the patient in regard to history, and social issues if the patient cannot speak for themselves, and may have the ability to made medical decision based on a medical power of attorney, living will, or current care-giver or spousal status.

CPT is very specific in regard to code selection for admission and subsequent visits in regard to counseling/coordination of care. 50% (or more) of the time spent. must be documented as counseling and/or coordination of care to bill by time default. Otherwise the guidelines of history, exam and medical decision making must be followed. As the coder you need to carefully read the guidelines set for by CPT in the CPT manual.

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