Coding and Reimbursement Essentials for Ophthalmologists, Part 2

Can I submit a claim for services provided to family members?

According to the Center for Medicare and Medicaid Service (CMS), physicians can’t bill for services they provide to family members. Commercial payers follow this rule, too. So who exactly is a family member? The following degrees of relationship are included within the definition of immediate relative:

• Members of the your household
• Domestic partners
• Your husband or wife
• Your natural or adoptive parent, child or sibling
• Your stepparent, stepchild or stepsibling
• Your grandparents, grandchildren or their spouses
• Your father in-law or mother-in-law
• Your son-in laws or daughter-in-laws

Note: A brother-in-law or sister-in-law relationship does not exist between a physician and the spouse of his wife’s (or her husband’s) brother or sister. A father-in-law or mother-in-law relationship does not exist between a physician and his/her spouse’s stepfather or stepmother. A step-relationship and an in-law relationship continue to exist even if the marriage upon which the relationship is based terminates through divorce or through the death of one of the parties. Thus, for example, if a physician treats his stepfather after the death of his natural mother or after the stepfather and natural mother are divorced, or if he treats his father-in-law or mother-in-law after the death of his wife, the services are considered to have been furnished to an immediate relative and are excluded from coverage.

Can I bill for a meeting with the patient's family when the patient is not present?

Generally speaking, there is no service billable unless the patient is present. CMS’ Internet-Only Manual (IOM) publication 100-03, chapter 1, section 70.1 discusses consultations with family members. This section discusses the appropriateness of obtaining history from the family members when the patient is unable to provide the necessary history. This would be part of the E&M service for that particular encounter.

What about counseling members of the household? Where there is need to observe the capability of and assist the family members in the management of the patient, counseling principally concerned with the effect of the patient's condition on the family members would not be a covered service.

In addition, IOM publication 100-02, chapter 15, section 30 indicates that reimbursable physician services are those services provided to the patient.

If the situation you have meets the qualifications listed above, the services may appropriately be billed to Medicare under the patient's Medicare number. If not, then the charge would be to the patient's family, so long as you have notified them ahead of time in writing.

Can I have multiple fee schedules?

Yes. All payers, whether federal or commercial, have different rules, regulations and fee schedules, and it is important to have a handle on them. You can create multiple fee schedules, but keep in mind that your Medicare Part B charges cannot be higher than your usual and customary fee schedule. The exception to this may be made on a case-by-case basis where physicians may have a separate fee schedule for the uninsured patient — if the patient is able to pay at the time of service. Many offices charge the full fee schedule, but will reduce the amount if the patient pays at the time of service, thus saving billing expenses.

Should I show payment amounts on claim submissions?

Never list payment amounts on claim submissions. Payers may subtract the amount paid from the charged amount, therefore lowering your fee to less than what the payer allows.

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About the author: Jennifer Arbuckle, CPC, OCS, is an Academy coding specialist whose background includes coding, billing, compliance and reimbursement in both a small private practice and a large academic medical institution.