Wiki Office visit with pediatric patient present

[pvacanti]

We see pediatric patients in our office and on occasion the parents/guardians will come to the appointment without the patient. Can we bill for an E&M code to insurance even though the patient is not present? If so how would the doctor dictate his note? Would he code according to time?

 

[theresa.mandl@msn.com]

No, the patient must be present for the visit. Medical Necessity dictates the patient must be present for the encounter for it to be a billable service.
Hope this helps
Theresa M.

 

[mitchellde]

you can use 99358 for this encounter as long as a minimum of 30 minutes is documented.

 

[pvacanti]

Thank you!!!