Family meetings without the patient present

December 29th, 2015 - Codapedia Editor
Categories:   Coding   Compliance   Primary Care|Family Care  
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Medicare does not permit a physician practice to bill for family meetings without the patient present.  The physician may not bill Medicare, nor may they bill the family member.  It is fairly common for the spouse or child of a patient to ask to see the physician to discuss the patient's care.  The meetings can be quite lengthy and involve a lot of physician time.  For Medicare, however, unless the patient is present, there is no payment for the service.

You may not bill the family with or without an ABN, because the service is considered bundled, not non-covered.

State Medicaid programs have different policies: check with them.

For commercial payers, ask them if they follow CPT® or Medicare guidelines in relation to this.

CPT® codes are defined, when using time to select the code, as "discussion with the patient and/or family." This means that for commercial payers, a physician could bill for discussion with the patient family within CPT® rules.  However, the correct diagnosis code would be V65.19, "Other person consulting on behalf of another person." Using that V code may result in a denial from the payer.  If the payer denies the service as "Incidental" or "bundled," and you have a contract with the payer, you can't bill the patient or family for the service.  If the denial is "non-covered" then you can typically bill the family member who requested the service.

If the patient is present for the meeting, then the service is reportable and reimburseable.  See the article on using time to select a code.

See the article about critical care, and what time with the family may and may not be included.

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