Ophthalmology and Optometry Coding Alert

Question: A patient comes in to discuss the care of his wife, who is also a patient and whom the surgeon is treating for macular degeneration. The surgeon spent 30 minutes with the husband, describing treatment options, possible outcomes, etc. Because the wife isn't present, may I bill the visit?


Arizona Subscriber

Answer: The E/M codes include "face-to-face with the patient and/or the family." But most private payers follow Medicare's policy and don't cover encounters in which the patient isn't present. Most insurers reimburse only for services that the physician delivers directly to the patient unless the patient is unable to make care decisions for herself, in which case the meeting with the caregiver is considered to be the same as a meeting with the patient.

In this case, however, you should consider the visit a service to the person who is in the office.

Counseling comprises more than 50 percent of the visit, in this case 100 percent. So, you should select the appropriate level of E/M service based on time. For a 30-minute established patient office visit, you should report 99214 (Office or other outpatient visit for the evaluation and management of an established patient... physicians typically spend 25 minutes face-to-face with the patient and/or family).

Do this: For the diagnosis code, use either V61.49 (Health problems within family; other), which includes care of or presence of a sick person in the family or household, or V65.19 (Other person consulting on behalf of another person), which includes advice or treatment for a nonattending third party. If the payer does not reimburse for these codes, you may be able to bill the patient, such as the husband in this case.

Extreme caution: The best solution is to require that the patient be present for counseling appointments that include an appropriate level of examination. Many coders and payers would not consider this a billable service unless the wife was with the husband at the time of the physician encounter.