Fam Pract Manag. 1998 Jul-Aug;5(7):22.

Coding a nursing-home visit


When I accept a nursing-home patient into my practice, I always meet with the patient's family members. I schedule 30 minutes to one hour (usually after office hours) to discuss the family's concerns and related issues. Will Medicare reimburse me for this time? Do I have to see the patient the same day I see the family and up the level of visit from a 99311 to a 99312?


The situation you described — seeing a patient's family in the common occurrence. Unfortunately, CPT is not very clear on how to code this scenario.

The conversation you described falls under CPT's definition of “counseling” as used in conjunction with the evaluation and management (E/M) services. Specifically, CPT says, “Counseling is a discussion with a patient and/or family ...” (emphasis added). First, you need to decide whether the counseling is being provided for the family's benefit or the patient's benefit. If it is for the family's benefit, you might consider billing the family's insurer for the service using the appropriate E/M codes.

If you decide the counseling is a service to the patient, then billing becomes more problematic. With the exception of care plan oversight and services billed “incident to,” Medicare generally assumes that when you bill an E/M service for the patient, you actually saw the patient on that date of service. Thus, you probably would have to see the patient and use one of the codes for subsequent nursing facility care (99311-99313). Remember to include the family counseling in the service (since the CPT descriptor does).

If counseling dominates the service, you may code on the basis of time, which may raise the level of visit from 99311 to 99312. Otherwise, you must code the level of visit based on two of the three key elements associated with E/M services (history, exam and medical decision making).

The documentation for the service should conform to one of the currently accepted versions of the documentation guidelines for E/M services. If counseling or coordination of care dominates the service, the guidelines require that the record document the total length of the encounter and describe the counseling or coordination of care performed.

For a definitive answer to your question, please contact the AMA's CPT Information Services at 800-634-6922.

Notifying patients and insurers when a physician leaves


Our group practice recently dismissed a physician who is now employed by another practice in our city. Should we notify our patients and the health plans we contract with that we no longer employ this physician? Does the dismissed physician have legal rights to the patients?


A lot will depend on the terms of the dismissed physician's contract with your group. If the contract stipulates that your group owns the patient charts, you are not obligated to notify patients of the physician's move, only to provide continuous care to the patients. You may wish to mail letters to the patients notifying them of their reassignment to another physician in your group. If the contract stipulates that the physician has rights to the patients, it is his or her responsibility to notify patients about the change. If patients wish to transfer to another practice, you should provide the new physicians with copies of the patients' charts upon request.

Your group should keep the health plans it contracts with informed of any changes in physicians' employment status so they can update their files and ensure a correct listing in their provider directories. Shifting patients to other physicians in your group should not be a problem as long as the physicians are participating providers under the patients' health plans.

*Denotes charter member of the Academy's Network of Consultants.


Copyright © 1998 by the American Academy of Family Physicians.
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