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Internal Medicine Coding Alert

Reader Question:

Medicare and Family Counseling Visits

Published on Fri Feb 01, 2002

Question: The daughter of one of our Medicare patients made an office appointment to discuss her mothers ability to care for herself and continue to live on her own. Her mother (our patient) was not present and was unaware that her daughter was meeting with our physician. Should we use the time factors of the evaluation and management codes to bill our patients Medicare, or bill the daughter directly?

Florida Subscriber
 
Answer: Although CPT defines E/M counseling as a discussion with a patient and/or family, to bill this encounter to Medicare, CMS requires the patient to be present to use the time factors of these codes.
 
While most of the time, encounters of the type you describe can be billed directly to the family member who meets with the physician, you may be able to bill the conference and counseling time factors of the E/M codes (99212-99215) if the family members visit meets the coverage requirements outlined in the Medicare Coverage Issues Manual. According to the manual, Medicare will pay for a visit with a family member if the patient is withdrawn and uncommunicative due to a mental disorder or comatose and the physician needs information from family members to aid in the diagnosis or treatment of the patient. The Medicare Coverage Issues Manual states, When a physician contacts his patients relatives or associates for this purpose, expenses of such interviews are properly chargeable as physicians services to the patient on whose behalf the information was secured.
 
Note that in the instance cited above by Medicare, the physician is requesting information from the family to aid in the patients treatment. The family is not requesting advice or guidance from the physician as in your example. 
 
Apart from a physicians need to obtain information about a patient to assist in diagnosis and treatment, Medicare also covers counseling to family members under two circumstances:

 1. When there is a need to observe the patients interaction with family members; and/or when there is a need to assess the capability of and assist the family members in aiding in the management of the patient.

 2. When the counseling is directed at the treatment of the patients condition. It is never covered when it is aimed at dealing with the problems of the family members, including the effect of the patients illness on the family.
 
If the time your physician spent with the patients daughter discussing her mothers condition does not fit into the exceptions described above, it would be appropriate to charge the visit to the daughter.
 
More information regarding Medicares coverage requirements for family meetings without patient contact can be found at www.hcfa.gov/pubforms/06_cim/ci00.htm, click on 35 - Medical Procedures and locate policy 35-14.

  Answers for You Be the Coder and Reader Questions were reviewed by Linda Bishop, CPC, CCS, corporate compliance officer, Pediatric Management Group at Childrens Hospital, Los Angeles; and Kathy Pride, CPC, CCS-P, HIM applications specialist with QuadraMed, a national healthcare information technology and consulting firm based in San Rafael, Calif.

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