One of the thorniest coding questions is: Can a physician bill for family meetings when the patient is not present? If so, who gets the bill ?
One of the thorniest coding questions is: Can a physician bill for family meetings when the patient is not present? If so, who gets the bill - the insurance company, family member, or patient? Unfortunately, the AMA’s Current Procedural Terminology (CPT) and Medicare each answer this question differently.
Let’s start with Medicare. Medicare does not allow billing for family meetings without having the patient present. If I want to have a meeting with my mother’s doctor (without having her present) to discuss her diabetes care plan, the doctor cannot bill anyone for this service, even Medicare. Why? Because Medicare considers this part of the pre- and/or post-workup for an E&M service. In addition, this conference may not be billed even if there is an Advance Beneficiary Notice because it is considered a bundled service, not noncovered. This is a long-standing Medicare policy.
What about non-Medicare payers who follow CPT rules? The CPT definition of an E&M service specifically includes mention of the patient and/or family:
"Physicians typically spend XX minutes face-to-face with the patient and/or family."
When discussing how to use time to select a code in the introductory section for E&M services, the CPT manual says:
"When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter…"
This seems to imply that an E&M service may be provided to a family member on behalf of a patient. Why might this be necessary? A parent may want to discuss a child’s care without the child being present. In this case, if the payer follows CPT rules, a physician could bill the encounter as a meeting with the parent. The physician would bill the service based on time, document the nature of the counseling, and describe the reason why the service did not include the patient.
For the diagnosis code, in addition to the condition being treated or discussed, you should add V65.19: "Other person consulting on behalf of another person." Using the V code may result in a denial from the payer, but correctly informs the payer that the patient was not present at the visit.
If the payer denies the service as "incidental" or "bundled," and you have a contract with that payer, you can’t bill the patient or family for the service. If the reason for the denial is "noncovered" then you can typically bill the family member who requested the service.
In the hospital, family meetings that include the patient may be billed based on time, as long as more than 50 percent of the time is spent in discussion. For Medicare, the patient must be present for the family meeting to be reimbursed.
Finally, what about family meetings for critically ill patients? Family meetings called for the purpose of updating family members cannot be included in critical-care time, and are not billable. However, if the physician meets with a family member to obtain a medical history (where the patient is too ill to provide this himself) or one who is the medical decision maker for a critically ill patient (who cannot make her own decisions), this time may be included in critical care.
With the adoption of the Resource-Based Relative Value Scale, many physician activities are considered part of the pre- and post-workup for patient encounters and may not be separately reimbursable. So do your homework first before billing for family meetings.
Betsy Nicoletti is the founder of Codapedia.com. She is the author of “A Field Guide to Physician Coding.” She believes all physicians can improve their compliance and increase their revenue through better coding. She may be reached at firstname.lastname@example.org or 802 885 5641.