Oncology & Hematology Coding Alert

Question: How can I bill for family meetings in which the patient is not present?

New York Subscriber

Answer: Evaluation and management (E/M) service codes should be used to bill for family meetings, as long as the visit meets the criteria for counseling (defined below). The appropriate level of service is determined by the amount of face-to-face time the physician spends with the family.

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

Diagnostic results, impressions and/or
recommended diagnostic studies;
Prognosis;
Risks and benefits of treatment options;
Instructions for treatment options;
Risk factor reduction; and
Patient and family education.

The most important components in selecting a level of E/M service are history, examination and medical decision-making. Counseling, coordination of care and the nature of the presenting problem are considered contributory factors. Time is the final component and represents the actual face-to-face time a physician spends with the patient and/or family.

An exception to the key components occurs when the visit is predominantly (more than 50 percent) spent in counseling or coordination of care. This encounter can be with physician and patient and/or family. Time and the nature of the presenting problem will assist in determining the appropriate level of service. The face-to-face time, however, is the controlling factor. Family is not limited to relatives and includes time spent with the parties who have assumed responsibility for the care of the patient or decision-making regardless of whether they are family members, such as foster parents or a legal guardian. As always, 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. There are situations, however, in which the patient is not present, and the visit can be billed by applying the above guidelines. The physician and family-only visit most commonly would occur when the patient is a minor or is not capable of understanding the information provided. These scenarios are not limited to these two populations, however. If the physician sees the patients family for counseling, the level of service is determined by the face-to-face time spent with the family. Codes 99211-99215 (office or other outpatient visit) should be used depending on the time spent from 5 minutes to 40 minutes.

Note that coordination of care with other providers or agencies without a patient encounter on that day is reported using the case management codes.

Editors note: Answers were provided by Laurie Lamar, RHIA, CCS, CTR, CCS-P, reimbursement specialist with the American Society of Clinical Oncology in Alexandria, Va.; and Margaret Hickey, RN, MSN, MS, OCN, an independent healthcare consultant and former clinical director at Tulane Cancer Center in New Orleans. (Lamars response does not reflect the opinion or position of ASCO.)