Medicare Compliance & Reimbursement

Question: A parent of a large family came into the office with two sick children who were then diagnosed with and treated for strep throat. The pediatrician also prescribed antibiotics for the rest of the siblings who were not present. This entailed going into each sibling’s chart and checking their medications and their history and then performing some decision-making. Is there any way to bill for these siblings who were not actually present in the office? Codes 99212-99215 allow the face-to-face time to be with a family member, but since these patients do not have an actual diagnosis, the doctor wants to bill 99401. What is the correct way to go about billing for these patients?

Answer: Unfortunately, this is a situation where the physician is doing real work, but it is not for the patient being seen, so it’s not a billable service. Additional time-based coding could be done if it is related to counseling and coordinating care for the patient and parents related to the patient’s problem.

In addition, 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) would not be appropriate. This is a code for non-problem-related counseling (preventive medicine counseling such as anticipatory guidance). It should also be related to the patient being seen face-to-face, which your visit was not.

Unfortunately, therefore, there is no appropriate way to bill for the non-face-to-face work that your pediatrician provided to the siblings who are not present.