Pediatric Coding Alert

Question: A patient’s family came in, and our pediatrician spoke to them about the child’s diagnosis and made a plan with the family. Can this be billed if the child was not present due to the child’s age and diagnosis?

AAPC Forum Participant

Answer: Yes, it is perfectly possible to bill for an appropriate level of office/outpatient evaluation and management (E/M) service in situations like this.

That’s because CPT^® defines total time for office/outpatient evaluation and management (E/M) services as including “counseling and educating the patient/family/caregiver.” Under this situation, family counseling without the patient would qualify.

Further, CPT^®’s Counseling Guidelines state that “counseling is a discussion with a patient and/or family,” (emphasis added). The “or” here can be taken to mean that the patient does not have to be present.

However, some payers may interpret these guidelines differently, and may insist that the patient be present during the encounter in order for you to be reimbursed for the office/ outpatient E/M service. So, you should verify a specific payer’s policy before billing.