Primary Care Coding Alert

Question: A patient comes in to discuss the care of his wife, who is also a patient and recently had a heart attack. Our family physician spent 30 minutes with the husband, describing healthcare options, recovery time and diet restrictions. Since 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. Therefore, you should consider the visit a service to the person who is in the office.

Counseling comprises more than 50 percent, in this case 100 percent, of the visit. 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).

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.

-- Answers to You Be the Coder and Reader Questions provided by David I. Berland, MD, American Academy of Child and Adolescent Psychiatry codes and reimbursement committee chairman and AACAP adviser for the AMA CPT Advisory Committee; Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.; and Marie Felger, CPC, a family practice coding consultant and American Academy of Professional Coders-certified coding instructor with Joy Newby & Associates LLC in Indianapolis.