I've read all the referenced articles and studied my CPT/ICD-9 books. The issue I'm still stumped on is the term "present". The patient was on the speakerphone at home talking to the doctor during the follow-up visit. The wife was physically present in the room with the doctor.
I can't determine what "present" really means. The patient was present via the phone...but not physically present. He had a presence in the room through the phone.
You cannot bill Medicare if the patient is not present. For payers that follow CPT guidelines, the patient does not have to be present for outpatient office visits.
Outpatient established patient visits (99212-99215) state: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: History, Exam and MDM. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the PATIENT’S and/or FAMILY’S needs. Usually, the presenting problem(s) are of ... severity. Physicians typically spend xx minutes face-to-face with the PATIENT and/or FAMILY.
Note: "Physicians typically spend xx minutes face-to-face with the PATIENT AND/OR FAMILY."
CPT defines COUNSELING as: a discussion with a PATIENT and/or FAMILY concerning one or more of the following areas: diagnostic results, prognosis, risks, benefits and instructions for management, compliance, education.
CPT defines face-to-face time (office and other outpatient visits and office consultations): For coding purposes, face-to-face time for these services is defined as only that time that the physician spends face-to-face with the PATIENT AND/OR FAMILY. This includes the time in which the physician performs such tasks as obtaining a history, performing an exam, and counseling the PATIENT AND OR FAMILY.
CPT further states: When counseling and/or coordination of care dominates (more than 50%) the physician/patient AND/OR FAMILY encounter, then time may be considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members.
Based on CPT, you may report the established patient visit (99212-99215) based on time under the patient’s name even when the patient is not present. CPT allows you to use time as the controlling factor when counseling and/or coordination of care dominates the service. For outpatient coding, time includes face-to-face time between the PATIENT AND/OR FAMILY member. Documentation must include the encounter’s total face-to-face time, the counseling time, and a brief counseling summary.
Time-based coding does not require the encounter to meet any of the visit’s otherwise required key components. Established patient office visits that are not comprised mainly of counseling and/or coordination of care would have to meet or exceed two of the level’s history, examination, or medical decision making requirements. Since time-based coding does not require an exam, you can use time-based coding when the patient is not present. You choose the office visit code based on the visit’s documented total face-to-face time.
Medicare usually does not pay for visits that do not involve face-to-face contact between the patient and physician. This patient present requirement may have led you to assume that there was no coding alternative for these cases, but according to CPT there is.
Definition of Service
Medicare: "When counseling and/or coordination of care dominates (more than 50%) the outpatient/office face-to-face physician/patient encounter or the inpatient floor/unit time, time is the key or controlling factor in selecting the level of E&M service."
2010 CPT: "When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face in the office or outpatient setting or floor/unit time in the hospital or NF), then time may be considered the key or controlling factor to qualify for a particular level of E&M service. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members."
Considering both Medicare and CPT, some payers will allow for billing of counseling and/or coordination of care encounters with the patient's family (spouse, child, parent, guardian), when the patient is not present. Typically, the family is acting on behalf of the patient, due to the patient's age (a minor) or due to the patient's medical condition (sedated, coma, dementia, etc.).
Encounters with the patient's family, and the patient is not present for any portion, should be:
• Medically necessary, with the primary focus on the care & treatment of the patient.
• A regularly scheduled appointment in the outpatient or office setting
• Coded with a primary diagnosis of V65.19 = "Person consulting on behalf of another person, advice on treatment for non-attending third party (the patient)." The patient's condition may be listed as the secondary diagnosis. NOTE: Medicare will likely deny the claim, but this is the correct coding.