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Internal Medicine Coding Alert

Reader Question:
Understand Guideline Conflicts in This Absent Patient Scenario

Question: We have a mom that came in for a consult about her 5-year-old son, but he was not present. Can I bill an evaluation and management (E/M) visit based on time under the 5-year-old's insurance even though he was not present? Or can we bill anything at all for this visit if we code Z71.0?

Nevada Subscriber

Answer: CPT® states that"face-to-face time" is "only that time spent face-to-face with the patient and/or family." The "and/or" part of that means the patient does not have to be present from a CPT® perspective, so you can regard this as a counseling session and you could, as you say, report it as a service attributed to the absent patient with an appropriate E/M level from 99201-99215 (Office or other outpatient visit for the evaluation and management of a ... patient ... spent face-to-face with the patient and/or family).

As you also suggest, because this is a counseling session, you would choose the appropriate E/M code calculated by time and use diagnosis code Z71.0 (Person encountering health services to consult on behalf of another person) to document the encounter.

You should, of course, check with the payer first to see if its policies allow this. Some payers may only cover office and other outpatient visits provided in the presence of the patient for whom the claim is submitted. For instance, even though the 1995/1997 Medicare E/M documentation guidelines both use the same "and/or" language as CPT®, the Medicare Claims Processing Manual states, "In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported." (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf (30.6.1.C))

Other payers, including state Medicaid programs, may have similar guidelines. If the payer in question is like Medicare, consider reporting the encounter as a service to the mother, since she was physically present.