Forum - Questions & Answers

Jun 11th, 2009 - efuhrmann

medicare vs AMA

I think I understand that Medicare requires a service is billable only is it is face to face with the patient, therefore a visit is not billable to Medicare if the encounter is with family but the patient is not present. Could someone cite a reference from Medicare to support this rule?

Jun 11th, 2009 - nmaguire   2,606 

Patient not present

When a family comes to the office to talk about a patient who is not there Medicare is clear that the beneficiary must be present to bill Medicare in such a scenario. No Medicare patient present, no bill to Medicare. Make it clear to caregivers or relatives in advance that the visit will be on a cash basis.

Jun 11th, 2009 -

No reference

but it's the truth. We all know it- no patient, no payment.

Jun 12th, 2009 - Codapedia Editor 1,399 

Family member only for Medicare patient

I'll look for the citation over the weekend.

Jun 12th, 2009 -

medicare reg

thanks.

Jun 15th, 2009 -

medicare

were you able to find a reference for this rule?

Jun 15th, 2009 -

Indirect references- no CMS reference

http://compliance.uclahealth.org/workfiles/PDFs/Counseling_or_Coordination_of_Care.pdf
http://www.uabhealth.org/12719/

Jun 21st, 2009 - Codapedia Editor 1,399 

Medicare: beneficiary not present

I've been looking in the manuals for the reference that states that for Medicare patients, the patient must be present to bill an E/M code. I've checked the Chapter 1, 12, and 30 of the Claims Processing Manual, and Chapter 15 of the Medicare Benefit Policy Manual. I can't find it.

Does anyone know in what manual it resides?

Jun 21st, 2009 - nmaguire   2,606 

E/m

Pub. 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS)Transmittal 178
B - Selection of Level Of Evaluation and Management Service Instruct physicians to select the code for the service based upon the content of the service. The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) or more than 50 percent of the floor time (for inpatient services) is spent providing counseling or coordination of care as described in subsection C. Any physician or non-physician practitioner (NPP) authorized to bill Medicare services will be paid by the carrier at the appropriate physician fee schedule amount based on the rendering UPIN/PIN.
"Incident to" Medicare Part B payment policy is applicable for office visits when the requirements for "incident to" are met (refer to sections 60.1, 60.2, and 60.3, chapter 15 in IOM 100-02).
The CPT definition of face-to-face time is defined as "only that time that the physician spends face-to-face with the patient and/or family." Note that inpatient encounters are different because CPT defines unit/floor time as both time spent at the patient bedside and on the unit/floor rendering services for that patient.
How can a physician perform cognitive services (history; physical; and medical decision making) without a face to face??



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