# Please help! Second time posting this question...



## lisamarhea

I could really use some feedback on this situation:
One of the doctors that I work for saw a patient's family to discuss the pt's new diagnosis of MS. On the same day, the patient was having an infusion done in the office, but was not in the room. The doctor states he spent an hour discussing the pt's diagnosis with the family, and wants to know if this is billable. (FYI: Pt's insurance is Anthem, PHP)
Here's what I'm thinking, and please someone let me know if I'm correct: We can bill the established office visit code 99215 because it states "patient and/or family" and more than 50% of the time spent was regarding counseling/coordination of care. I would also put a modifier 25 on it because I'm billing out the infusion on the same day. 
There wouldn't be any use of the "prolonged service codes", correct? Because the time would only be 20 minutes longer than the amount of time listed for the 99215 code. 

Thanks for anyone's reply!


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## Walker22

That sounds correct to me...


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## Schuyler

that is exactly what I would do-


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## ashack63

You stated the patient was in the office for an infusion. Did the physician examine the patient the same day he discussed the new diagnosis with the family. If he did not meet the criteria for an E & M level (Hx, exam, MDM) you can not bill out an E & M code


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## Walker22

anne1607 said:


> You stated the patient was in the office for an infusion. Did the physician examine the patient the same day he discussed the new diagnosis with the family. If he did not meet the criteria for an E & M level (Hx, exam, MDM) you can not bill out an E & M code



I respectfully disagree. "When more than 50% of the encounter is taken up by counseling (in this case, it's 100%), then TIME becomes the key or controlling factor to qualify for a particular level of service". That quote is straight from the CPT book.


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## lisamarhea

Yes, that is what I was thinking... thanks so much for your help!


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## Herbie Lorona

I do not agree with that. I believe the patient would still need to be there face-to-face with the physician. If you look under the Definitions of Commonly Used Terms it states under new and establisht patient - profesional services are those face-to-face services. What if it was a patient that had never been seen and the family comes in to talk about a diagnosis with the dr before he see's the patient for the first time. Would you bill a New patient since the family was counselled for that?


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## Walker22

Herbie Loroña said:


> I do not agree with that. I believe the patient would still need to be there face-to-face with the physician. If you look under the Definitions of Commonly Used Terms it states under new and establisht patient - profesional services are those face-to-face services.



I was addressing the OP in which the patient was already established. Meeting with the family IS a face-to-face service.

99212-99215 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components.
-detailed history
-detailed exam
- MDM of moderate complexity

Physicians typically spend XX minutes face-to-face with the patient AND/OR THE PATIENT"S FAMILY.

When counseling dominates the physician/patient AND/OR FAMILY ENCOUNTER, then TIME may be considered the key to qualify for a particular level of service.

I stand by my comment.


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## Walker22

Herbie Loroña said:


> What if it was a patient that had never been seen and the family comes in to talk about a diagnosis with the dr before he see's the patient for the first time. Would you bill a New patient since the family was counselled for that?



How can a doctor talk about a diagnosis with the family if he/she has never seen the patient? How can there even BE a diagnosis?


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## Herbie Lorona

Here is what I got from the CMS website.

C - Selection Of Level Of Evaluation and Management Service Based On Duration Of Coordination Of Care and/or Counseling
Advise physicians that when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, *the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided*. Documentation must be in sufficient detail to support the claim.


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## Herbie Lorona

Also:

*In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported.* Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.


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## Walker22

That may be CMS's interpretation of the rules, but the patient in this scenario had BCBS. CMS rules do not apply here.


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## Herbie Lorona

The physician still needs to have 2 of the 3 key components but when determining the level to bill you can use the time as the key or controlling factor to qualify for a particular level of E/M services


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## Walker22

Herbie Loroña said:


> The physician still needs to have 2 of the 3 key components but when determining the level to bill you can use the time as the key or controlling factor to qualify for a particular level of E/M services



We have that... History and MDM

I don't really want to argue about this anymore. Our disagreement seems to exist because we are approaching the problem from different perspectives. You seem to be approaching it from a "what will get paid" point of view, and that is perfectly understandable. My approach is from the wording in the CPT book alone. Not every service is covered by all payers. You can code something correctly and still not get paid because of payer interpretation of the guidelines. In the case outlined in the OP, I believe an office visit is the correct code to bill. Whether it will get paid or not is a different question...

Happy Holidays!


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## Herbie Lorona

Well I am not looking at it from a "What will get paid" point of view. Really how do you bill an office visit for a patient who was not in the office. I know the insurances will pay if you submit a bill. You would want to use prolonged services. CPT states in prolonged services that to bill prolonged services "it must relate to a service or patient where direct (face to face) patient care has occurred or will occur and relate to ongoing patient management."


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## Walker22

Herbie Loroña said:


> I know the insurances will pay if you submit a bill.



Really? You must live on a different planet than I do. Just submitting a bill is not a quarantee of payment. You still have to follow their guidelines.


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## Walker22

Herbie Loroña said:


> You would want to use prolonged services. CPT states in prolonged services that to bill prolonged services "it must relate to a service or patient where direct (face to face) patient care has occurred or will occur and relate to ongoing patient management."



Who said anything about "Prolonged Services"? I was referring to the 99212-99215 codes.


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## Walker22

Herbie Loroña said:


> Yeah I am quite aware of that. But with all the fraud going on you can submit bills when the patient was never in the office and get them paid. Basically what you are saying to go ahead and do!



Excuse me, but I am not, nor will I ever, condone any kind of fraud and I resent the implication that I would. I am merely interpreting the CPT guidelines as written in the CPT book.


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## Walker22

Herbie Loroña said:


> Yeah you should be billing prolonged services not E&M



The prolonged services codes are add-on's for E&M services. You can't bill them without first billing an E&M code, so your statement makes no sense.


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## Walker22

Herbie Loroña said:


> So I guess next time I will just go to the Pediatrician without my daughter and just tell him to bill for an office visit!



I think you are missing the point, but whatever. I'm done with this conversation. Have a nice life.


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## Herbie Lorona

Well 99358 is not a add on code and it states that "(face-to-face)patient care has occurred *or will occur*and relate to ongoing patient management


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## Walker22

Herbie Loroña said:


> Well 99358 is not a add on code



Yes it is, dude. Look again.


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## Herbie Lorona

Walker22 said:


> Yes it is, dude. Look again.



Well it is for 2009 but 2010 it was revised and is no longer an add on code.


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## LTibbetts

Herbie Loroña said:


> Yeah you should be billing prolonged services not E&M
> 
> So I guess next time I will just go to the Pediatrician without my daughter and just tell him to bill for an office visit!



Wow, I think you are WAY out of line, here. One of the best things about being a coder is the fact that our coding is ultimately based on guidelines and then our own interpretations and there will ALWAYS be times when coders have to respectfully agree to disagree and I think that that is all that Walker22 is trying to do. Accusing someone of fraud or any kind of fraudulent type of activity is absurb and you should be ashamed of yourself. These forums are for coders to bounce things off one another, give advice and help each other, and there are going to be many instances where we will not agree or come to the same conclusions. I love these forums and wouldn't be able to go one day without at least checking in. I wouldn't be as eager to do so if I was constantly met with reactions such as yours. I little clue, though, when someone says that they do not want to argue about something any longer, I suggest you let it go and go about your own business. If you both disagree, then so be it. This bantering back and forth makes you look ridiculous and no one will take you seriously when you act that way in life. 
As far as what the actual initial post is about, I agree with Walker22 but that is only MY opinion....

Be nice, all we have is each other in this world...


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## LTibbetts

FYI, it is not 2010 yet so the 2009 codes still apply.


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## LLovett

*Wow, is it getting hot in here?*

Well, I could be wrong but it looks like 99358 is no longer an add on code in 2010. They have revised it and my CPT book no longer shows the plus sign indicating it is an add on. Of course it is not 2010 yet, so right now it is an add on.

While it is not allowable to bill for an E/M service when the patient is not present under CMS guidelines, it is allowed under CPT. The original question is in regards to a non-medicare patient. Whether or not that insurance follows CPT or CMS I don't know but ultimately I would default to CPT until otherwise directed by the carrier.

Do I personally agree with billing high level E/Ms to talk to the family when the patient is not there, it depends on the situation but in general no I am not a fan of it. Is it allowable, yes. You just better be sure the documentation supports it.

Just my 2cents but I wanted to add in order to bring the focus back to the original question. I know I am guilty of passionate responses myself but it is important to stay on target.

Happy Holidays

Laura, CPC, CEMC


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## Herbie Lorona

Either way it still does not make sense to bill for an office visit under a patients name if the patient is not in the office


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## Walker22

Thanks Leslie and Laura for offering your opinions. I would be interested in hearing from more coders on this issue. This is a very interesting discussion!


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## LTibbetts

If it was my case, personally, I agree with Laura in that I would bill it under the default CPT guidelines unless I heard otherwise from the billing department. You can always call BC and ask them directly what they would pay and if they adhere to CMS guidelines or CPT guidelines in this particular instance. Again, I agree with Laura as far as billing a higher E/M and being *very* careful to back yourself up with proper documentation before going that route. After 2010, however, my opinion on this matter would definitely vary but either way, I would contact the payer directly and ask them.


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## Walker22

Herbie Loroña said:


> Well it is for 2009 but 2010 it was revised and is no longer an add on code.



I don't use the 2010 CPT book until it's _actually_ 2010.


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## LTibbetts

I couldn't agree more!!


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## Walker22

See this thread for a related discussion....

https://www.aapc.com/memberarea/forums/showthread.php?t=26678


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## hsmith67

*My 2 cents*

I took a week long CPC coding boot camp sponsored by one of the large companies that do them around the country. I actually took it 1.5 times (got the flu in the middle of one and they let me retake full course at no additional charge). This very issue came up - counseling family members without patient being present and it created a heated discussion. Long story short, the instructors of both classes are very well versed, very well credentialed, many years of experience between them, one even has a book published specifically on E/M coding, and both agree - the way you bill for this is via the E/M codes for OV. 

Yes Herbie, OV E/M without patient present is billable. It created a bit of debate, albeit not as heated as it got here on one side, but as stated, reading the guidelines exclusively within the AMA CPT book, that is the correct thing to do. Whether or not it makes sense or not to bill a "patient visit without the patient present" is not the issue. Given circumstance "A" what do I bill is the issue. Given this circumstance, the applicable E/M OV is to be billed based on time spent as "greater than 50% of time spent on education and/or counseling" (as it was 100% of time spent since patient was not present to do a physical exam, take history, etc.). 
Cheers and Happy New Year!


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## LTibbetts

hsmith67 said:


> I took a week long CPC coding boot camp sponsored by one of the large companies that do them around the country. I actually took it 1.5 times (got the flu in the middle of one and they let me retake full course at no additional charge). This very issue came up - counseling family members without patient being present and it created a heated discussion. Long story short, the instructors of both classes are very well versed, very well credentialed, many years of experience between them, one even has a book published specifically on E/M coding, and both agree - the way you bill for this is via the E/M codes for OV.
> 
> Yes Herbie, OV E/M without patient present is billable. It created a bit of debate, albeit not as heated as it got here on one side, but as stated, reading the guidelines exclusively within the AMA CPT book, that is the correct thing to do. Whether or not it makes sense or not to bill a "patient visit without the patient present" is not the issue. Given circumstance "A" what do I bill is the issue. Given this circumstance, the applicable E/M OV is to be billed based on time spent as "greater than 50% of time spent on education and/or counseling" (as it was 100% of time spent since patient was not present to do a physical exam, take history, etc.).
> Cheers and Happy New Year!




Well put! And thanks so much for the shared info!! Always good to hear another view.


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## mhcpc

*Cpt assistant on this subject*

I just received the CPT ASSISTANT for 12/09 and one of the questions answered is,  "When choosing a new or established outpatient E/M code, is it necessary to perform all three key components in order to qualify for reporting?"

ANSWER:  " As indicated in the descriptor language of the new and extablished outpatient E/M service codes 99201-99205, each of the three key components are required when reporting services rendered to _new_ patients.  *However, only two of the three are required when services are provided to *_established_patients.  As with most rules, there are exceptions.  An example of an exception would be when patient-visits consist primarily of counseling or coordination of care.  The E/M Services guidelines in the CPT codebook provides further information pertaining to the use of time in the selection of an appropriate level E/M service code."

I thought it was pretty neat that I just saw this discussion today after reading the CPT assistant that addresses this issue and backs up what the majority is saying.

Michele R. Hayes, CPC, CEMC. CGIC


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## Walker22

I'm still watching this thread closely. Thanks for everyone for giving their opinion. Keep them coming!


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## louLNC

I would not utilize that code as it is for a comprehensive visit with medical decision making of high complexity. Not knowing if the patient had an E&M complicates the answer. If the patient had an exam for the infusion by a physician or ancillary provider, NP or PA you should use the prolonged duration code which meets the most closely. I find the inappropriate use of level 5 claims those I most frequently find do not have adequate documentation to be paid. 
Hope this helps. 
Louise Cardillo, R.N. B.S. CPC, LNCC


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## Mjones7

First let me say that I too love the forum and find it resourceful I do however, think we should all treat each other respectfully and when we disagree, do it nicely.  We after all are professionals.  Ok now for my stance, I would have no problem coding for the face to face time my doc spent with pt's family as per my interpetation of the guidelines this is allowed.  I would however appreciate my doc meeting the time requirements in his documentation.  I in no way see this as fradulent in fact, I see it as capturing revenue earned correctly and accurately.  That is just my two cents on the issue.  Everyone have a great day.

 Live is ever learning; keep an open mind.


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## Lisa Bledsoe

*2010 CPT Changes Insiders View*

Hi All - FYI:  99358 and 99359 have had the add on status removed (although you can't use 99359 without 99358).  The publication states "however, the guidelines specify that the prolonged service must relate to a service or patient in which direct face to face care has occurred or will occure, and relate to ongoing patient management".

Hope this helps.
I too was very disturbed at the heated/angry turn that the post took.  We must *respectfully* disagree when we disagree, not become defense and attack one another.


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## Walker22

I agree that in 2010 these codes are no longer add-on codes, but the original discussion was about a DOS that occured in 2009, so I was using the 2009 CPT book as my source. Furthermore, I believe that I was as respectful as possible (I even said "I respectfully disagree"), and tried to end the debate before it got out of hand, to no avail.


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## Lisa Bledsoe

Walker22 said:


> I agree that in 2010 these codes are no longer add-on codes, but the original discussion was about a DOS that occured in 2009, so I was using the 2009 CPT book as my source. Furthermore, I believe that I was as respectful as possible (I even said "I respectfully disagree"), and tried to end the debate before it got out of hand, to no avail.



You are correct Walker 22, and I should have added that the original question was for 2009.  I just wanted to add that 2010 brought about a change in 99358-99359.  My comments were not directed at you, but to the post in general as it did get heated.  I think it was a difference of interpretation, understanding and opinion (since this covered a lot of ground) between you and Herbie Lorona.  I agree the 2010 CPT is not valid until 2010 and was pointing out the change effective for 2010 according to the Insiders View...
Just wanting the forum to remain a friendly place for all of us


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## Walker22

All is good


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## SCanterbury

I don't usually like to post a full CPT Assistant Q and A but I feel here it is warranted. The CPT book clearly states that counseling can be performed with the patient AND/OR family to qualify for an E/M code:

_CPT Assistant
December 2004 page 19
Coding Consultation:Questions and Answers
Evaluation and Management, (Q&A)

Question
What is the appropriate code to report for a service in which the physician provides only counseling and/or coordination of care regarding symptoms or an established illness to the family without the patient being present? 

AMA Comment
From a CPT coding perspective, time may be considered the key or controlling factor when the physician provides counseling and/or coordination of care that dominates (more than 50%) the patient and/or family encounter. For time to be considered a key component, the physician must spend face-to-face time with the patient and/or family (without the patient) in the office or other outpatient setting. This would include time spent with parties who have responsibility for the care of the patient or decision-making regardless of whether they are family members (eg, foster parents, person acting in loco parentis, legal guardians). The key components of history, physical examination, and medical decisionmaking do not need to be provided or documented when counseling and/or coordination of care dominates. Typical times are included in each code descriptor to assist in selecting the most appropriate level of E/M service. _
________________________________________

There are many reasons why this could be appropriate, such as a physician's need to gather additional history from the family/caretaker in his/her attempts to refine a patient's diagnosis, to discuss the patient's at-home care that will be performed by the family member/caretaker, and so on. These are usually necessary in cases where the patient is unable to provide meaningful history (due to senility or other) or cannot adequately comprehend or implement instruction given by the physician and so the family member must "step in" and help. If a patient is senile and it is not time for the next physical exam or diagnostic test, there is no medical need to drag them to the office to sit in the next chair while the doctor gives updated care instructions to the family member.

Medicare goes its own way, and has often said that it still prefers the patient to be present or else use the family counseling time in the next face-to-face E/M code billed. They also say that the MDM component must still be evident in the documentation. But that is Medicare, not CPT, and this is not a Medicare situation.

Seth Canterbury, CPC, ACS-EM


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## RebeccaWoodward*

How did I miss this thread????  

*Walker, way to hang in there!!* 

Seth...as always, your expertise is on the mark!


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## Walker22

rebeccawoodward said:


> How did I miss this thread????
> 
> *Walker, way to hang in there!!*
> 
> Seth...as always, your expertise is on the mark!



Thanks Rebecca! This is fast becoming my favorite thread... LOL


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## hthompson

So, I'm in the position to code a visit where the patient is terminal and not present.  The family came in to discuss the Drs. plan for the patient.  Our Drs. do not have hospital priveleges.  I read all 10 pages and I just about have a headache; however, since I am a coder and love my job, I'm trying to see it from both viewpoints.  I will respectfully have to agree with Walker22 and I will explain why.  I agree with the reasons given for office visit codes and in addition, it doesn't matter to me if Prolonged Physician Service Without Direct (Face-to-Face) Patient Contact (99358) is no longer an add-on code for 2010, the small print says that it is inappropriate for this use.  Here it is:

My CPT book specifically says, "Do not report 99358-99359 for time spent in medical team conferences, on-line medical evaluations, CARE PLAN OVERSIGHT, anticoagulation management, or other non face-to-face services that have more specific codes and no upper time limits in the CPT code set.  Codes 99358-99359 may be reported when related to other non face-to-face service codes that have a published maximum time (eg. telephone services).  

Is this discussion re: care plan oversight?  It is for me!  This seals the deal for me.  Office visit 99212-99215 it shall be.  I would personally use these prolonged codes if my Dr. told me and documented that s/he spent an hour or more reviewing records pertaining to a visit with the patient after the patient left. I would also use this if my Dr. received a pile of old records from another provider or from archives and the patient was new or established and going to come in at a later date or later that day for a visit.

My question is: what diagnosis would you use?  The patient's illness or V61.49?


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## SCanterbury

You would use the patient's diagnosis code AND a V-code. But I wouldn't use the V-code for sickness in the family. This code implies that the service revolves around the presenting _family member's issue_ that they have to deal with all of the problems associated with another family member who is sick. 

You would instead use V-code V65.19 _Other person consulting on behalf of another person_ under the V65.1 category, as this includes "advice or treatment for non-attending third party." Using this code along with the "non-attending" patient's dx code makes it clear to the payer that the patient is not physically present. If the specific payer has a problem with CPT's allowance that a doctor can meet with the family on behalf of the patient, they usually have edits tied to this code. Using it will give them the opportunity to deny it if they have a stricter policy than CPT that defines a face-to-face service as a service between the doctor and patient (not AND/OR family as CPT allows). 

Seth


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## hthompson

I agree, I figured that out during the last 2 months


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## SCanterbury

Yeah, sorry for the delay. I'm not on these boards very often...

Seth


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## hthompson

LOL, not your fault!  I just couldn't wait and then I forgot that I asked, so I didn't go back and answer my own question.


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