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Billing E&M code 99214 with 85060 cpt code with family member of the patient

Kathy k Posted Mon 09th of March, 2015 17:15:54 PM

Our oncologist would like to bill E&M code 99214-25 with cpt code 85060 with the patient's spouse (the patient was not present). The patient was too ill to come in to the clinic, but the husband and patient had too many questions and concerns they didn't want to cancel the appointment.

Is it ok to bill 99214-25 with 85060 (blood smear interpretation)?

DX: 205.0

SuperCoder Answered Tue 10th of March, 2015 03:42:10 AM

Looks like you want to bill based on time, for counseling and coordination of care provided to patinet's family, on the context of the Pt.'s illness.

The Medicare Claims Processing Manual Chapter 12 Section 30.6.1 Part C - "Selection of Level of Evaluation and Management Service Based on Duration of Coordination Of Care and/or Counseling" suggests:

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. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service.

This confirms that if you are selecting the level of service based on time spent counseling or coordinating care in the office setting, the patient must be present - even if you are counseling the family.

Medicare can allow a charge for time spent with the family in only two situations:

1. The physician is asking the family for history or discussing the options for the patient’s care when the patient is incapable of participating (unconscious, comatose etc.)

2. The services would fall under the mental health counseling provision of Medicare.

We really cannot recommend billing an E/M service for a patient who was not present.

For Medicare or other patients whose insurers follow Medicare rules, you can't bill CPT 85060 (Blood smear, peripheral, interpretation by physician with written report) unless the service is for a hospital inpatient (place of service 21). Medicare's logic for not paying 85060 for hospital outpatients or non-patients is that "payment for the underlying clinical laboratory test is made to the hospital, generally through the PPS [prospective payment system] rate."

In other words, Medicare holds that it has paid for the peripheral blood smear interpretation by paying for the lab test on the clinical lab fee schedule (such as CBC). Billing Medicare, secondary payers, or the patient would be double billing.

Check other payers: Not all payers follow this rule, so you can check 85060 coverage rules with your primary payers to see if the Medicare restriction applies.

Regardless of payer, you shouldn't bill 85060 if another physician has already interpreted the smear, or if the pathology report simply prints the cell counts without a written pathologist interpretation.

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