Gastroenterology Coding Alert

Question: My gastroenterologist wants to charge for a visit with a patient's son (who is also the patient's representative). He went over the patient's lab, medications, and plan of care. What should I do?

Kentucky Subscriber

Answer: Most insurers including Medicare will not reimburse for any E/M service your gastroenterologist provides -- even those strictly concerned with counseling or coordination of care -- if the patient is not present. Simply put, without face-to-face time with the patient, you haven't got a billable service.

These are the only exceptions:

Exception 1: If your 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," and according to the Medicare Carriers Manual, section 35-14, the patient is unable to provide the information himself.

In this case, you may be able to report a low-level visit, but expect Medicare to reject the claim unless your documentation is especially clear as to why contact with the family member was necessary.

Exception 2: The gastroenterologist must meet with the family member because the patient is incompetent or otherwise unable to make care decisions for himself.

If the family simply wishes to discuss the patient's condition with the physician -- and the service does not meet any of the two conditions mentioned above -- you can choose either to offer the visit as a courtesy or to bill the family member(s), not the patient, a set fee for this noncovered and not medically necessary service. To protect your reimbursement in the latter case, you should designate someone within the family to sign an advance beneficiary notice.