Pediatric Coding Alert

Question: I’m trying to code an encounter where a family consulted with a provider but the child did not come. The child did come earlier in the day to get updated height and weight but the parent did not want child to be present for the conversation. Can I bill for this visit with a regular evaluation and management (E/M) service code? I have looked online and it says that the patient needs to present. Is this correct?

Oregon Subscriber

Answer: No, the patient does not need to be present, and you can absolutely bill for and E/M visit in this situation.

There is reliable evidence to support such a consultation without the patient present. According to CPT^®’s counseling guidelines, “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. Also, consider what CPT^® says about leveling a service using total time. CPT^® defines total time for office/outpatient E/M services as including “counseling and educating the patient/family/caregiver.” Under this situation, family counseling without the patient would qualify.

However, in a scenario like this, you should use caution trying to bill for two E/Ms in the same day. Generally, only a single E/M code should be used to report all services provided for a patient on a given day. The descriptors don’t explicitly state that, but you’ll likely get pushback from the payer. Take a look at chapter 12 of the Medicare Claims Processing Manual, for example (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf), which states:

“…as for all other E/M services except where specifically noted, the Medicare Administrative Contractors (MACs) may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off the campus-outpatient hospital, or on campus-outpatient hospital setting which could not be provided during the same encounter (e.g., an office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).”

So essentially, if the two visits were clearly unrelated and the documentation supported that, you may be able to report both and append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). Otherwise, if a provider sees the patient twice in the same day, simply combine the work done at each encounter and level accordingly.