Oncology & Hematology Coding Alert

Question: Is it correct to bill an E/M visit for a family meeting despite the absence of the patient?

New York Subscriber

Answer: E/M codes should be used to bill for family meetings if they meet the criteria for counseling. The appropriate level of service is determined by face-to-face time spent with the physician and family.

E/M services are divided into broad classifications based on the type of service, place of service and patient's status. Counseling is one of the services that can be provided and differs from psychotherapy and is defined as a discussion with a patient and/or family concerning one or more of the following areas:
 

In determining the level of service, oncology practices must consider seven components:
 

Most often the key components in selecting a level of E/M services are history, examination and medical decision-making. These components require the presence of the patient. There is an exception to the key components when the visit is predominantly (more than 50 percent) spent in counseling or coordination of care, which may include the family. Time and the nature of the presenting problem will assist in determining the appropriate level of service. However, the face-to-face time is the controlling factor. Family is not limited to immediate relatives, but may include those who have assumed responsibility for the care of the patient or decision-making. The extent of the counseling and/or coordination must be documented in the medical record.

Most commonly in oncology settings, counseling visits include the patient and family. However, sometimes the patient is not present, and this visit can be billed applying the above guidelines. Most often the physician-and-family-only visit happens when the patient is a minor or the patient is not able to understand the information provided. Medicare requires that the patient be present for the visit; other payers may pay in the absence of the patient.