Can You Get Paid for a Visit Without the Patient?

Betsy Nicoletti, MS


August 19, 2019

Editor's Note:
Betsy Nicoletti, MS, a nationally recognized coding expert, will take your coding questions via email and provide guidance on how to code properly to maximize reimbursement. Have a question about coding? Send it here.

In this column, Nicoletti details the proper way to bill for visits without the patient present and how to get paid for medication management over the telephone.

Coding a Patient Visit…Without the Patient Present

Question: I am a pediatric neurologist, and the medical director of a developmental center.

The pediatric physicians at our center would like to meet with the parent(s) of a child without the child present, at times, for many reasons. We have received inconsistent and conflicting information from our billing and compliance staff.

Some say we may use evaluation and management (E/M) office visit codes (99201-99215) for meetings without the patient present, and some say we may not. How do we get paid for this service?

Answer: There are indeed times when you can get paid without the patient present at the visit. The Current Procedural Terminology (CPT) book has a clearly stated policy, but not all payers follow CPT rules. Codes 99201-99215, new and established patient office/outpatient codes, may all be billed on the basis of history, exam, and medical decision-making, or billed on the basis of time, if counseling dominates the visit. Each code has the typical time listed with these words: "Typically, XX minutes are spent face-to-face with the patient and/or family."

Following CPT rules, time spent with family members is acceptable in order to bill E/M services based on counseling time, when the time is spent in part or all with a family member.

Medicare, which is not a major payer in pediatrics, specifically says that the beneficiary must be present in order to bill these office visit codes.

Medicaid and private payers may or may not follow CPT rules. Your coding or compliance department may know whether there is a specific policy. If there is a specific policy (not a general one, such as "We follow CMS rules most of the time"), you must follow it. In the absence of a specific policy from your payer, such as Medicare's policy described above, follow CPT rules. Document the total time, the fact that more than 50% was spent in counseling, and the nature of the counseling.

The CPT rule holds true for all patients of all ages, if the payer follows CPT rules. Medicare specifically says it does not, and that the beneficiary must be present.

Bill Properly for Over-the-Phone Medication Management

Question: Can I use code 93793 for monitoring patients taking warfarin, if the management is done over the phone and not during a face-to-face visit? The patient has blood drawn at an outside lab, and after reviewing the results, our cardiology practice decides whether to keep the same medication dosage or make a change. My nursing staff calls the patient with the results.

Answer: The CPT definition for 93793 is "Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed."

The service described by 93793 is not a face-to-face service. According to CPT, it may not be done on the same day as an E/M service. If the management occurs on the same day as an office visit, bill only for the office visit, not for the anticoagulant management.

CPT Changes 2018: An Insider's View, an American Medical Association publication, states that 93793 is used to report the management services needed to treat the patient that are separate from an E/M service. The definition states "dosage adjustment (as needed) and scheduling of additional test(s), when performed." Because the definition says "as needed," you can still report the service if the management advice is to stay on the same dose of warfarin. And "when performed" tells you that scheduling of an additional test is not a required component of the code, but is included in the payment when it is done.

The work relative value unit for the code is .18, and the national payment amount is about $12.25. As always with CPT, a practice may not double-count time and effort. If the time of managing the warfarin is included in the time reported for chronic care management or transitional care management, do not bill for the anticoagulation management separately.

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