Gastroenterology Coding Alert

Question: Should we bill an office visit (99211-99215) for a consult with a family member to discuss a Medicare patient's condition if the patient is not present?

Michigan Subscriber

Answer: You cannot receive reimbursement from Medicare for discussions with a family member about a patient's condition if the patient is not present.

Medicare requires the physician to meet face-to-face with the patient to report an established patient E/M visit (99211-99215). The only exception is when 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," according to the Medicare National Coverage Determinations Manual, Chapter 1, Section 70.1.The patient must be unable to provide the information himself.

Prepare for rejection: For consulting with a family member, you may be able to report a low-level visit, but expect Medicare to 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 payable service, the consult must focus on the Medicare beneficiary's treatment.

A meeting with the family to explain the patient's condition is not payable, but a meeting to determine a family member's fitness to assist the patient to manage an illness may qualify (with proper documentation).

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 consult, Medicare bundles the code into other E/M services. Therefore, you cannot report it separately and expect payment.