How to bill when place of business isn't office; also, how to bill for a visit without a patient

April 9, 2010

Know how to process diagnostic tests out of the office, as well as discussions with a patient's family when a patient is not present.

Key Points

A: The Centers for Medicare and Medicaid Services (CMS) has given detailed instructions, effective January 4, regarding how to bill the place of service (POS). Here are the scenarios that Medicare has addressed in CMS Transmittal 1823, dated October 2:

Interpretation performed in a physician's home. Under such circumstances, the POS code would be either office (POS 11), if it meets the definition of office, or other (99).

Interpretation provided telephonically by wireless remote. The POS code for a teleradiology interpretation generally is the place where the interpretation is read. The ZIP code for the POS is based on the setting/location where the interpretation occurs.

Interpretation performed in an office suite that is neither the test location nor the physician's office. If the interpretation is performed in a location other than the main location of the physician group, and the location meets the definition of office, then the POS code is office (11). If the physician performs the interpretation from home, then the POS code is either office (11), if it meets the definition of office, or other (99).

Interpretation provided under arrangement to a hospital, separate technical component (TC) and professional component (PC). If a diagnostic test that has a separate TC and PC is provided under arrangement to a hospital, then the physician who reads the test can bill and be paid for the PC. If the interpretation is performed in the hospital setting, then the POS code is hospital outpatient (22). If the interpretation is performed at a location other than the location of the physician's office and the location meets the definition of office, then the POS code is office (11). If the physician performs the interpretation from home, then the POS code is either office (11)-if it meets the definition of office-or other (99). Note that when a physician performs a diagnostic test under arrangement to a hospital and the test and the interpretation are not separately billable, the interpretation cannot be billed by the physician. The hospital is the only entity that can bill for the diagnostic test, which includes the interpretation.

Date of service (DOS) for the PC of diagnostic tests. The appropriate DOS for the PC is the actual calendar date on which the interpretation was performed.

BILLING FOR A VISIT WITHOUT PATIENT

Q: I've instructed our staff members to bill using the 99499 code in situations in which a physician sees a patient's family member(s) without the patient being present. They have raised a good point, however: the description for 99214 (for instance) reads, "Physicians typically spend 25 minutes face-to-face with the patient and/or family." If the counseling and coordination-of-care portion of the office visit can include the patient or the family, then how can I explain this situation to my staff members?

A: You have correctly read a portion of the evaluation and management (E/M) code description. The rest of the description, however, includes: "Office or other outpatient visit for the evaluation and management of an established patient. . . ."

E/M codes require the patient to be present. The only codes in CPT that allow for discussion only with the patient's family (patient not present) are in the psychiatry section.

The author is a compliance manager for Baptist Medical Associates in Louisville, Kentucky. Have a coding or managed care question for our experts? Send it to medec@advanstar.com
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