Primary Care Coding Alert

Question: A child’s family consulted with a provider, but the child was not present. The child did come earlier in the day to be updated for height and weight, but the mother did not want the child to be present for the conversation. Can I bill for this visit?

Oregon Subscriber

Answer: Yes, and there is reliable evidence to support the medical necessity of such a consultation without the patient present. However, there are potentially three different ways you could report the visit with the mother.

One way is to consider it part of the total time spent related to the visit with the child earlier in the day., Consider what CPT^® says about leveling a service using total time. CPT^® defines total time for office/outpatient evaluation and management (E/M) services as including “counseling and educating the patient/family/caregiver on the date of the encounter.” Further, CPT^® total time on the date of the encounter “includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s)…” (Emphasis added). Under this situation, family counseling without the patient would qualify, whether you count it as face-to-face time with the family or non-face-to-face time relative to the patient (i.e., the child).

One alternative is to bill two E/M services for the same-day encounters and designate the child as the patient in each case. Generally, only a single E/M code should be used to report all services provided for a given patient on a given day by a physician or group of physicians in the same specialty. The descriptors don’t explicitly state that, but you’ll likely get pushback from the payer if you try to do otherwise. Take a look at section 30.6.7.B of chapter 12 of the Medicare Claims Processing Manual, for example:

“…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. However, if a provider sees the patient twice in the same day (or the patient and the patient’s mother, in this case), it is probably easier to simply combine the work done at each encounter and level accordingly.