Otolaryngology Coding Alert

Question: Should we bill an office visit (99211-99215) for a consult with a family member to discuss a patient's condition if the patient is not present?

Michigan Subscriber

Answer: You cannot receive reimbursement from Medicare for discussions with a family member about a patient's condition if the patient is not present.

Medicare requirements specify that the physician must meet face-to-face with the patient to report an established patient E/M visit (99211-99215). The only exception is when the physician must contact another individual (such as a spouse, parent, child, or other family member) to "secure background information to assist in diagnosis and treatment planning," according to the Medicare National Coverage Determinations Manual, Chapter 1, Section 70.1. The patient must be unable to provide the information himself.

Prepare for rejection: For consulting with a family member, you may be able to report a low-level visit, but expect Medicare to reject the claim -- unless your documentation is especially clear. The documentation must specify why that contact with the family member was necessary.

To qualify as a payable service, the consult must focus on the Medicare beneficiary's treatment. A meeting with the family to explain the patient's condition is not payable, but a meeting to determine a family member's fitness to assist the patient to manage an illness may qualify (with proper documentation).

Although 90887 (Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient) seems ideal to report a family consult, Medicare bundles the code into other E/M services. Therefore, you cannot report it separately and expect payment.

Non-Medicare patients: If the patient isn't covered by Medicare, the AMA definition of an E/M includes counseling and coordination of care with the patient's family and can include a visit without the patient. CPT states, for example for 99213, the following: Office or other outpatient visit for the evaluation and management of an established patient - Physicians typically spend 15 minutes face-to-face with the patient and/or family. Note the last three words: "and/or family."

Whether it is paid will be different from payer to payer. You can use the CPT description to appeal the determination by a non-Medicare third-party payer, but the payer's rules will determine the ultimate decision. If your practice finds itself having trouble with these situations frequently -- for example, a pediatric otolaryngology practice -- your physician will have to decide whether to continue to participate with that third-party payer.