Okay, next question. This is about a new patient consult with the family but the patient isn’t present.
So, the question is, “I work in an Outpatient Cancer Center Facility and have a question on a new patient E/M visit. We have a new patient that scheduled a second opinion/new patient consultation appointment. Patient’s family came into the office without the patient for second opinion regarding his disease management. The patient was too ill to come in to the appointment. Do you know if there is a New Patient E/M visit that we can bill? The visit was more than 30 minutes with more than 50% of the time in counseling.”
Definitely they’re putting their thinking cap on with this one, but I was able to pull up some research. I knew the answer from when I asked it like many years ago but I just like to still do the research to be thorough. And what I found is for the most part, most payers are not going to pay for that. It would be really a private pay situation where the physician would need to bill the patient or whoever is taking care of their bills. It should be really known upfront. That should be a part of the office policy to let the families know. That if the patient is not there, unfortunately, per payer policies, you cannot bill the insurance.
I did find a CMS reference, because mostly we’ll probably be dealing with patients that are Medicare when we’re getting into this need to not have the patient with you. It’s 70.1 Consultations with a Beneficiary’s Family and Associates. I do have a link. If you are in the Replay Club, you can just click on that and it will take you to this exact reference on the CMS website:
Basically what it says: “In certain types of medical conditions, including when a patient is withdrawn and uncommunicative due to a mental disorder or comatose, the physician may contact relatives and close associates to secure background information,” etc.
What I have highlighted here: “expenses of such interviews are properly chargeable as physician’s services to the patient on whose behalf the information was secured.”
We’ll read down here a little bit more: “Family counseling services are covered only where the primary purpose of such counseling is the treatment of the patient’s condition.” You have to have that met.
And a little bit lower: “Counseling principally concerned with the effects of the patient’s condition on the individual being interviewed would not be reimbursable…” So, this is Medicare standpoint.
Now, you might find a payer out there that will, you’d have to check with them.
Again, go with your top payers and find out what they do in the situation but what I’ve learned over the years and heard, I haven’t heard of very many payers that will actually pay for this. Okay? So, hopefully that will help you with that one. Sorry to be the bearer of bad news.
More Related New Patient Versus Consultation
AAPC – Consult vs New patients
CPT Versus HCPCS Codes – Video
By Laureen Jandroep
CPC, CPC-I.,Sr. Instructor for CodingCertification.Org. Resides in southern New Jersey with her husband of over 20 years Anthony and four children. They are active foster parents and spend most of their time these days just being parents which they love.
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