Neurology & Pain Management Coding Alert

Question: Does CPT include a code we can use when the physician sees the patient's family in the hospital but does not have a face-to-face visit with the patient? The closest I find is 96155. Is that correct?

Wisconsin Subscriber

Answer: Code 96155 (Health and behavior intervention, each 15 minutes, face-to-face; family [without the patient present]) might not be the most appropriate code if the reason for the visit doesn't fit the code's criteria. The Instructions for Use of the CPT Codebook directs coders to "Select the name of the procedure or service that accurately identifies the service performed. Do not select aCPT code that merely approximates the service provided."

Check out this example of 96155 from the AMA. A 41-year-old male is diagnosed with pancreatic cancer. He is undergoing aggressive chemotherapy and radiation treatment, and his prognosis is guarded. The patient isn't in the end-stage disease process so he doesn't qualify for hospice care. The patient is seen initially to address issues of pain management via imagery, breathing exercises, and other therapeutic interventions to address quality of life issues, treatment options, and death and dying issues.

Because of the medical protocol and the patient's inability to travel to additional sessions between hospitalizations, a plan is developed for extending treatment at home via the patient's wife, who is the primary home  caregiver. The health care provider trains the wife to assist the patient in objectively monitoring his pain and in applying exercises learned via his treatment sessions to manage pain. Issues of the patient's quality of life, as well as death and dying concerns, are also addressed with assistance given to the wife as to how to make appropriate home interventions between sessions.Effective communication techniques with her husband's physician and other members of his treatment team regarding his treatment protocols are facilitated. The physician's code for this service is 96155.

Another option to consider would be +99358 (Prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family]); first hour [List separately in addition to code[s] for other physician service[s] and/or inpatient or outpatient evaluation and management service), depending on the length of the visit. Note in this code's description, though, you can only report the addon code +99358 in conjunction with a direct face-to-face E/M service.

Caution: Medicare does not allow either of the above CPT codes for processing. 96115 carries a "N" code (or non-covered service) status indicator and 99358 carries a "B" code (or bundled service) status. Medicare mainly won't reimburse for non face-to-face patient services, but private payers may have their own guidelines. If the patient's payer doesn't recognize this type of service, consider charging the patient's family a flat fee for the physician's time that's payable up front.

-- Clinical and coding expertise for You Be the Coder and Reader Questions provided by Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.