American College of Physicians: Internal Medicine — Doctors for Adults ®

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Billing for interactions with a patient's family, caregivers

From the November ACP Internist, copyright © 2008 by the American College of Physicians

By Brett Baker

According to the AARP, a nonprofit organization representing people age 50 and older, more than 44 million Americans care for an adult family member or friend. Physicians often will discuss the care of a patient with the patient's caregivers, and may be able to bill for these interactions.

Q: May I bill Medicare for time I spend interacting with a family member or other caregiver who supports my patient?

A: Medicare rules make it possible for you to bill for the time you spend discussing issues related to the care of the patient with a family member or other caregiver. Medicare views a caregiver as someone who has responsibility to care for the patient and/or assist with decision-making. The limitations on billing for the time you spend training, educating and/or instructing the caregiver are:

  • The caregiver interaction must occur during an encounter with the patient for whom you provide a service that Medicare considers to be medically necessary;
  • Providing guidance to the caregiver cannot be the sole reason for the encounter, even if the patient is present during the visit; and
  • You must choose to select the level of evaluation and management (E/M) service you will bill to Medicare for the encounter involving the patient based on amount of time you spend with the patient and the caregiver.

Q: How would I choose a level of E/M service based on the amount of time spent with the patient and caregiver?

A: History, examination and medical decision-making are the key components in selecting a level of E/M service. Counseling, coordination of care and nature of presenting problem are contributory factors. These contributory factors are important but not required to be provided at every patient encounter. A typical time for most E/M services, which represents an estimation of the average amount of time involved in furnishing each service, is listed in the Current Procedural Terminology (CPT) codebook.

You can, however, use time as the key factor in selecting a particular level of E/M service when counseling and/or coordination of care accounts for more than half of the face-to-face time you spend with a patient. Face-to-face time is defined as direct interaction with the patient and family/caregiver in the office or other outpatient setting and time spent on the floor/unit in the hospital or other inpatient setting.

When instructing a caregiver in the outpatient setting, you can count the time on these activities whether or not the patient is in the same room—although the patient visit must be for a medically necessary service that involves direct interaction with the patient. Assuming it is an established patient, you would select the appropriate outpatient established office visit service code, from the range CPT 99211-99215, based on how the total face-to-face time for the visit compares with the typical time assigned to the codes in the CPT book. As an example, you would bill CPT 99214 for a 30-minute encounter that involves 20 minutes of counseling and/or coordination of care with the patient and/or caregiver because the total time exceeds the typical 25 minutes for that code, but falls short of the 40-minute typical time for CPT 99215.

When instructing a caregiver in the inpatient setting, you can count the time that you spend on these activities at the patient bedside or on the floor/unit, which can take place outside the presence of the patient. Assuming it is a hospital visit after you initially admit the patient, you would select the appropriate subsequent hospital care code, from the range CPT 99231-99233, based on how the total face-to-face time for the visit compares to the typical time assigned to the codes in the CPT book. As an example, you would select CPT 99233, the highest level subsequent hospital visit, if you spend 25 minutes of a 40-minute face-to-face encounter instructing the patient and/or caregiver on the hospital floor.

It is important that you document the time and nature of your interaction/instructions to the caregiver and broader counseling and/or coordination of care activities if they are also involved in the encounter in the patient's medical record.

Q: How is counseling defined?

A: Be sure that the interaction with the patient and/or caregiver for which you are counting the time to determine which level of E/M service to bill to Medicare is related to counseling and/or coordination of care. Medicare uses the CPT definition of counseling as a discussion with a patient and/or family concerning one or more of the following areas:

  • diagnostic results, impressions, and/or recommended diagnostic studies,
  • prognosis,
  • risks and benefits of management (treatment) options,
  • instructions for management (treatment) and/or follow-up,
  • importance of compliance with chosen management (treatment) options,
  • risk factor reduction, and
  • patient and family education.

Q: Am I violating patient privacy rules in discussing the patient's condition with a caregiver, even if it is a family member?

A: CMS maintains federal regulations that implement the patient privacy provisions included in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). These federal regulations permit physicians to disclose information, referred to as protected health information (PHI), to a family member, relative, close personal friend, or any other person identified by the individual when the PHI is directly relevant to the person's involvement with the individual's care or payment for the care. A physician can disclose PHI to these persons if the patient is present and does not object to the disclosure or the physician can reasonably infer from the circumstances that the individual does not object to the disclosure. If the individual is not present or is incapacitated, the physician can make the disclosure if, in the exercise of professional judgment, he or she believes the disclosure is in the best interests of the patient. Patient privacy regulations are not meant to impose a barrier to physician interaction with caregivers.

Q: Will Medicaid pay me for providing instructions to caregivers?

A: Medicaid is administered jointly by the federal government and each state government. State Medicaid programs have the discretion to make separate payment for caregiver services. Check with your state Medicaid program to determine if it covers caregiver services in your state. Use CMS-maintained HCPCS code, T1027, "family training and counseling for child development, per 15 minutes," to bill Medicaid for services to caregivers.

Q: Are resources available that aim to help enhance my interactions with caregivers?

A: CMS maintains a section on its Web site for Medicare beneficiaries devoted to caregiver issues.

Brett Baker is Director of ACP Regulator and Insurer Affairs. E-mail your coding questions.

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