Wiki E/M without the patient there?

[Orthocoderpgu]

We have a very eldery patient who is sundowning, will pass away soon and is basically bedridden. The family made an appointment with the patients doc and received counseling for the patient's end of life care. The CPT states that you can counsel the patient and/or family. But my question is, since the patient is bedridden and was not at this visit, can it be billed? I wish docs would consult with coders before making appointments.

 

[RebeccaWoodward*]

We have a very eldery patient who is sundowning, will pass away soon and is basically bedridden. The family made an appointment with the patients doc and received counseling for the patient's end of life care. The CPT states that you can counsel the patient and/or family. But my question is, since the patient is bedridden and was not at this visit, can it be billed? I wish docs would consult with coders before making appointments.

70.1 - Consultations With a Beneficiary's Family and Associates
(Rev. 1, 10-03-03)
CIM 35-14
In certain types of medical conditions, including when a patient is withdrawn and uncommunicative due to a mental disorder or comatose, the physician may contact relatives and close associates to secure background information to assist in diagnosis and treatment planning. When a physician contacts his patient's relatives or associates for this purpose, expenses of such interviews are properly chargeable as physician's services to the patient on whose behalf the information was secured. If the beneficiary is not an inpatient of a hospital, Part B reimbursement for such an interview is subject to the special limitation on payments for physicians' services in connection with mental, psychoneurotic, and personality disorders. (This particular scenario doesn't apply)

A physician may also have contacts with a patient's family and associates for purposes other than securing background information. In some cases, the physician will provide counseling to members of the household. Family counseling services are covered only where the primary purpose of such counseling is the treatment of the patient's condition.
For example, two situations where family counseling services would be appropriate are as follows: (1) where there is a need to observe the patient's interaction with family members; and/or (2) where there is a need to assess the capability of and assist the family members in aiding in the management of the patient. Counseling principally concerned with the effects of the patient's condition on the individual being interviewed would not be reimbursable as part of the physician's personal services to the patient. While to a limited degree, the counseling described in the second situation may be used to modify the behavior of the family members, such services nevertheless are covered because they relate primarily to the management of the patient's problems and not to the treatment of the family member's problems.

https://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf

 

[sofcampbell]

I have to deal with similar situations relatively often. At my previous job we had elderly adults and their relatives would come; now we have parents that don't want their kids being present during their conversations with a physician. So even though CPT allows counseling of a family member(s) and technically you can bill for an E/M based on that counseling time, your carrier may not cover the service and the patient/family will be responsible. So you will need to contact the carrier(s) and find out about their policy. For example, I know that Trailblazer for Medicare accepts only “face-to-face with a patient” services. It will be also a good idea to inform family in advance so that they aren't unpleasantly surprised by a future bill.
After you find out about your carrier's policies, it will also help if the group or physicians you work for documents their own policy. External auditors appreciate this kind of documents.

Thanks,

Sofia MS, CPC