Spending time with a family to discuss a child’s illness or problem without having the child present is a frequent occurrence in a pediatric practice. As the child, not the parents, is the patient, can these services be billed when the child is not present? The answer is yes! The following questions demonstrate the uncertainty in reporting these services.

Generally, the selection of an evaluation and management (E/M) service code is based on the performance and documentation of the 3 key components of history, physical examination, and medical decision making. The exception to this rule is when face-to-face counseling or coordination of care requires more than 50% of the total face-to-face time for the encounter. Time may then be used as the key or controlling factor in the selection of the code. Face-to-face time in the inpatient or nursing facility is defined as floor or unit time dedicated to the...

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