General Surgery Coding Alert

Question: Can 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?

North Carolina Subscriber

Answer: More than likely, you cannot 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). The only exception is 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," according to the Medicare Carriers Manual, section 35-14. This would require that the patient be unable to provide the information himself. If this is the 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 the reason that contact with the family member was necessary.

Above all, to qualify as a payable service, the consult must focus on the treatment of the Medicare beneficiary. 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).

CPT code 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), although seemingly ideal to report a family consult, is consistently bundled by Medicare into other E/M services. Therefore, you cannot report it separately and expect payment.