Internal Medicine Coding Alert

Question: A patients family asked our internist to review some test results and give an opinion about the advisability of surgery. He discussed the patients case at length with her current internist at the hospital and with her husband. He spent about 1.5 hours doing this but never saw the patient. The time is documented in the chart. Can we bill Medicare for this service? If so, how?

Practice Manager
Tarrytown NY

Answer: Sorry, no. Medicares hard-and-fast rule is No patient; no pay. Therefore, you cant bill Medicare for a confirmatory consult if the patient is not present.

You could bill the patients family. However, unless your internist informed the family in advance, billing them now might create unpleasant public relations. The more prudent course would be to absorb the cost on this particular consult, but plan for similar future ones, especially if your practice frequently receives requests for non-face-to-face patient care (as such services can take up a great deal of the physicians time).

To recoup reimbursement, develop a statement in which you explain the internist is available to render extensive consults with family members, but such services are not covered by Medicare and may be billed to the patients family. Post this in the waiting room, and have it on hand to give to family members at the hospital. (By using the word may, the internist is not under obligation to bill everyone. Yet, by making the policy clear in advance, he or she can bill it if the consult becomes time-consuming.)

Also, check with your top five insurance companies to see how they interpret non-face-to-face service. And remember to distinguish between confirmatory requests generated by the patients family and those required by the insurance company. For example, if the internist is rendering a second opinion required by another payer, then append codes 99271-99275 (confirmatory consultations, new or established patient) with modifier -32 (mandated services). This will help the payer identify the service they requested. Also, the patient usually has a lower out-of-pocket expense in those cases.

What you cant do is bill 99358-99359 (prolonged physician service without direct face-to-face patient contact). These prolonged service codes are meant to be added on to the initial Evaluation and Management (E/M) services code and the visit with the patients family does not have such a code. You also cant use these prolonged services unless a particular time limit has been exceeded. With a confirmatory consult, you dont know at what point you exceeded the highest level by 30 minutes since no average times are designated for these codes.