General Surgery Coding Alert

Question: My surgeon met with an elderly patients family to discuss treatment options and the patients plan of care. The patient was not present for this inoffice meeting. Can I still bill Medicare an E/M service based on the time spent with the family? What about if a patient is there with the family but due to cognitive issues is not mentally present or participating? Vermont Subscriber Answer: CPT does allow you to report new and established patient office visits without the patient present. When counseling and/or coordination of care account for more than 50 percent of the face-to-face time that the physician spends with the patient and/or family, you may use time as the key factor when determining the E/M service level. In these cases, you do not have to use history, examination, and medical decision making as the key factors. Because counseling comprises the majority of the visit [...]