Otolaryngology Coding Alert

Question: The otolaryngologist diagnoses a 10-year-old patient with sinus disease and recommends surgery, which he discusses with the mother that day. Both parents come back for another visit without the patient to discuss surgery and have a lot of questions and concerns. Should the doctor bill for the visit with the parents without the patient present?

New York Subscriber
 
Answer: Because the parents-only visit is a counseling session, you should bill for the visit (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient) based on time. When counseling consumes more than 50 percent, or in your case 100 percent, of an established patient office visit, the physician may use time as the key factor in selecting the appropriate level of E/M code, according to CPT.

Face-to-face time with the patient and/or family counts in determining the code selection. Make sure your otolaryngologist documents total time, time of the counseling, and what the physician discussed with the parents. It is not a bad idea also to include start and stop times of the counseling.

Because your example deals with a child, and children do not usually qualify for Medicare coverage, you are probably dealing with a private payer. But if the claim involves Medicare, the visit may still qualify as a billable service.

Medicare covers family counseling services absent the patient (1) when there is a need to observe the patient's interaction with family members, and/or 2) when there is a need to assess the capability of and assist the family members in aiding in the management of the patient. In your example, the parents need to evaluate the treatment options and determine the course they will follow. Therefore, the situation would qualify for coverage under Medicare's second requirement.