# How to bill when patient is not present



## 1073358

I had an office visit yesterday where the patient's mother and caregiver came for the appt but the patient did not. Patient is 60 something and on Medicare. He has a mental d/o and does not understand things, therefore they did not bring him to appt. The appt was to discuss a new cancer dx with the mother and caregiver and figure out where to go next.
What is everyone's policy on billing different insurances when patient not present?


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## rthames052006

1073358 said:


> I had an office visit yesterday where the patient's mother and caregiver came for the appt but the patient did not. Patient is 60 something and on Medicare. He has a mental d/o and does not understand things, therefore they did not bring him to appt. The appt was to discuss a new cancer dx with the mother and caregiver and figure out where to go next.
> What is everyone's policy on billing different insurances when patient not present?



In these cases what our office policy is to bill the family for the service, they are aware of this at the time the appointment is made, your not going to find many insurances who will pay for this type of service.

A few years ago we found that 1 insurance pd for it and that was GHP... we've had no luck with it, so thats why we have this policy in place.

Good luck,


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## FTessaBartels

*Counselling & Coordination of Care*

Page 8 of CPT 2008 Professional Edition states: (emphasis added by me)
"When counseling and/or cooridnation of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting...) then time may be considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with *parties who have assumed responsibility for the care of the patient or decision making* ... The extent of counseling and/or coordination of care must be documented in the medical record."

In the scenario you present, the patient is not mentally competent to understand and make medical decisions, so his mother / caregiver are the decision makers.

The physician should document:
   TOTAL time spent in face-to-face contact w/ decision maker
   WHY patient unable to participate in decision making
   Time spent in counselling/coordination of care
   The extent of the counselling / coordination.

As an example:
I spent 30 minutes face-to-face with Mrs X.  Mrs X is the medical decision maker for patient Y who has dementia and is unable to participate in his own medical decision making. 100% of this visit was spent in counselling/coordination of care, discussing recent cancer diagnosis of patient and treatment alternatives. 

This example could be billed as 99214.

Documentation is key in billing counselling/coordination of care. I'm assuming that your office has paperwork appointing Mrs X as the legal/medical guardian for the patient.

F Tessa Bartels, CPC EMA


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## valleycoder

i dont think you can bill medicare for that visit though.  there has to be a face-to-face visit with the patient....if this is incorrect, someone speak up....


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## 1073358

1015378 said:


> i dont think you can bill medicare for that visit though.  there has to be a face-to-face visit with the patient....if this is incorrect, someone speak up....



I agree. You can not bill Medicare. So in this case bill the patient's family?


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## rthames052006

1015378 said:


> i dont think you can bill medicare for that visit though.  there has to be a face-to-face visit with the patient....if this is incorrect, someone speak up....



I completely agree with you...

That is why our office came up with billng the family member for the service up front, no insurance involved...

Maybe in the future your office could have the pt show up with the family and doctor can see pt, then have pt leave the room to discuss with family members prognosis, treatment etc....  just an opinion.


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## cmac

we recently had a similar situation. wife came in regarding husband who is in nursing home, unable to make decisions, with her aware at time of service we billed her insurance for a consult based on time spent using diagnosis discussed regarding husband. in this case it was humana gold choice but they paid and all she had to pay was her copay. hope this helps.


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## ESORENSEN

*Non-physician services patient not present*

How 'bout health education and advice to a caregiver pertaining to a patient who is not present.  Service is being provided by an RN.  How should i bill this out?  98960 specifies "face-to-face" with the patient so that won't work.  I was looking at 96155 and am thinking that may be appropriate.  What do you guys think?


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## mitchellde

As far as physician encounter when patient is not present what about 99358-9 prolonged non face to face.  It is not add on any more and should cover this type of scenario.


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## j.berkshire

Here is some information worth looking into.  See this from the IOM # 100-03:  

http://www.cms.gov/Manuals/iom/item...r=ascending&itemID=CMS014961&intNumPerPage=10

70.1 - Consultations With a Beneficiary's Family and Associates
(Rev. 1, 10-03-03)
CIM 35-14
In certain types of medical conditions, including when a patient is withdrawn and uncommunicative due to a mental disorder or comatose, the physician may contact relatives and close associates to secure background information to assist in diagnosis and treatment planning. When a physician contacts his patient's relatives or associates for this purpose, expenses of such interviews are properly chargeable as physician's services to the patient on whose behalf the information was secured.


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## Lisa Bledsoe

I agree with Debra on this as far as code selection.  The way I interpret these codes, there would have to be a face to face visit with the patient at some point, but not necessarily on the same date according to CPT.


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