Anesthesia Coding Alert

Question: Should we bill an office visit (99211-99215) for a consult with a family member to discuss a patient's condition if the patient is not present?
Wyoming Subscriber
 
Answer: It's unlikely you'll receive reimbursement from Medicare for discussions with a family member about a patient's condition if the patient is not present. Medicare requirements specify that the physician must meet face-to-face with the patient to report an established patient E/M visit (99211-99215).

Exception: If the physician must contact another individual -- such as a spouse, parent, child, or other family member -- to "secure background information to assist in diagnosis and treatment planning," the E/M may be payable, according to the Medicare National Coverage Determinations Manual, Chapter 1, Section 70.1. The patient must be unable to provide the information herself, such as when a patient is comatose or uncommunicative/withdrawn due to a mental disorder. In this case, you may be able to report an appropriate-level E/M service, but Medicare may still reject the claim unless your documentation is especially clear. The documentation must specify why that contact with the family member was necessary.

To qualify as a Medicare payable service, the E/M service must focus on the Medicare beneficiary's treatment. Family counseling services when there is a need to assist, or assess the capability of, the family members in aiding in the management of the patient would be appropriate with proper documentation. In contrast, counseling primarily concerned with the effects of the patient's condition on the individual being interviewed would not be reimbursable as part of the physician's personal services to the patient.

Look out: Although 90887 (Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient) seems ideal to report a family counseling session, the Medicare "B" status indicator classifies this code as a bundled service. Therefore, you cannot report it separately and expect payment.

-- Answers to You Be the Coder and Reader Questions were provided by Scott Groudine, MD, an Albany, N.Y., anesthesiologist; Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver; and Kelly Dennis, MBA, CPC, ACS-AP, with Perfect Office Solutions of Leesburg, Fla.