Internal Medicine Coding Alert

Question: The internist spent more than an hour with a family discussing an elderly patient's arthritis care. The discussion included the physician answering the family's questions and thoroughly explaining the patient's treatment. How should we bill for this?

Montana Subscriber

Answer: If the patient was not present during the discussion, you'll have a hard time getting your internist paid. Based on the time your physician spent with the family, you may report prolonged services without face-to-face contact (+99358, Prolonged evaluation and management service before and/or after direct [face-to-face] patient care ...).

Remember, however, that Medicare and most private carriers consider payment for 99358 included in other E/M service that involved direct patient contact (for example, +99354, Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service ...).