Neurology & Pain Management Coding Alert

Question: Can a neurologist code 90846 when he or she meets with family (in the hospital or office) without the patient to discuss treatment, care and questions regarding the patient?

Georgia Subscriber

Answer: Code 90846 (family psychotherapy [without the patient present]) is specific to psychiatric services and should not be used. New patient (99201-99205) or established patient (99211-99215) evaluation and management (E/M) codes are based in part on time spent face-to-face with the patient and/or family.

According to CPT 2001, when counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the care of the patient or decision-making whether they are family members (e.g., foster parents, person acting in locum parentis, legal guardian) or not.

The extent of counseling and/or coordination of care must be documented in the medical record. Use the documented time to determine the level of service and report the appropriate E/M code.

Answered by Susan Callaway, CPC, CSS-P, an independent coding consultant and educator in North Augusta, S.C.