Anesthesia Coding Alert

Question: How should I code our pain management specialist performing a routine block on a family member? Is there a rule or law that says that a physician working on a family member is illegal or unethical? I've heard you cannot bill Medicare for it if you do -- in other words, a physician's services on a family member would be free.

Nevada Subscriber

Answer: Medicare does address the issue of physicians performing procedures on members of their family in Chapter 16 "General Exclusions from Coverage" of the Claims Benefit Manual, as follows:

"These [procedures or services] are expenses that constitute charges by immediate relatives of the beneficiary or by members of their household. The intent of this exclusion is to bar Medicare payment for items and services that would ordinarily be furnished gratuitously because of the relationship of the beneficiary to the person imposing the charge. This exclusion applies to items and services rendered by providers to immediate relatives of the owner(s) of the provider. It also applies to services rendered by physicians to their immediate relatives and items furnished by suppliers to immediate relatives of the owner(s) of the supplier."

What it means: This Medicare exclusion is for providing medical services to immediate family members and people living in the physician's household. Medicare's concern was services normally done for free due to familial relationships would and could be billed to Medicare unless this exclusion existed. This exclusion also applies to medical suppliers -- a physician can't charge his wife for a back brace he supplied.

Big tip: Additional information that defines-"immediate relationships"-and "members of household" is available at http://www.cms.hhs.gov/manuals/Downloads/bp102c16.pdf.

Remember: There are some insurance contracts that may incorporate-similar CMS regulations into their own polices, which would prohibit billing for the service provided. Keep an eye out for individual payer.