Primary Care Coding Alert

Question: A Medicare patient's daughter scheduled an appointment with the family physician to discuss her mother's care. The patient was not present during the visit. The physician's notes don't mention the amount of time spent discussing the patient with the daughter, or exactly what they discussed. Is there a code we can report to capture this encounter?

Wisconsin Subscriber

Answer: Medicare typically only reimburses care when the physician documents face-to-face time with the patient. The limited exceptions under which Medicare covers consultations with a beneficiary's family are described in section 70.1 of chapter 1 of the Medicare National Coverage Determinations Manual, which you may find online at http://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf It is not apparent that your situation fits these limited exceptions, so in all likelihood, your physician provided a service that is not payable under Medicare.

You do have an option to consider for next time, however: View the encounter as a service to the daughter. Under this option, you would report the encounter using an appropriate evaluation and management code with a diagnosis code reflecting that the encounter was for health problems within the family (e.g., V61.49, "Health problems within family; Other"). Because many payers might not cover family consults, verify the benefits beforehand. Bill the visit to the payer, if possible. If billing the payer isn't possible, let the family member know that she'll be expected to pay cash for the appointment. Some offices charge a flat fee for such visits, and others charge in 15-minute increments. Discuss the possible scenarios with your physician to determine the best payment structure, and encourage your physician to document the time spent and nature of the counseling provided in such situations.