Medicare Compliance & Reimbursement

Question: A patient’s wife presented to talk about her husband’s colonoscopy results and diverticulitis, treatment options, and which medications he should take. How can we bill for this visit?

Michigan Subscriber

Answer: The answer will depend on which insurer covers the patient. According to CPT^® rules, if the patient’s family members present to the practice to discuss the patient’s condition with the physician, you should report the visit based on time that the family members spend with the doctor using an E/M code from the 99201-99215 series.

Because the doctor is performing counseling based on an active condition that the patient has, you are justified in reporting the appropriate E/M code based on face-to-face time counseling or coordinating care. When you’re billing based on time, CPT^® defines “face-to-face time” as “only that time spent face-to-face with the patient and/or family. This includes the time spent performing such tasks as obtaining a history, examination, and counseling the patient.” Because CPT^® uses the language “with the patient and/or family,” it’s clear that the patient need not be present to report these codes under CPT^® rules.

Medicare rules: Although CPT^® rules support reporting the E/M codes without the patient present, the Centers for Medicare and Medicaid Services (CMS) states that the patient has to be present. Therefore, in cases where the provider meets with the family of a Medicare patient and the patient is not there, you cannot bill for the service. Obtaining a waiver from the family member is prudent if they have agreed to pay cash for the service. An ABN (advanced beneficiary notice) is not required because Medicare never pays for such a service.