CMS Pub. 100-03, ch. 1, § 70.1

CIM 35-14

In certain types of medical conditions, including when a patient is withdrawn and

uncommunicative due to a mental disorder or comatose, the physician may contact

relatives and close associates to secure background information to assist in diagnosis and

treatment planning. When a physician contacts his patient’s relatives or associates for

this purpose, expenses of such interviews are properly chargeable as physician’s services

to the patient on whose behalf the information was secured. If the beneficiary is not an

inpatient of a hospital, Part B reimbursement for such an interview is subject to the

special limitation on payments for physicians’ services in connection with mental,

psychoneurotic, and personality disorders.

A physician may also have contacts with a patient’s family and associates for purposes

other than securing background information. In some cases, the physician will provide

counseling to members of the household. Family counseling services are covered only

where the primary purpose of such counseling is the treatment of the patient’s condition.

For example, two situations where family counseling services would be appropriate are

as follows: (1) where there is a need to observe the patient’s interaction with family

members; and/or (2) where there is a need to assess the capability of and assist the family

members in aiding in the management of the patient. Counseling principally concerned

with the effects of the patient’s condition on the individual being interviewed would not

be reimbursable as part of the physician’s personal services to the patient. While to a

limited degree, the counseling described in the second situation may be used to modify

the behavior of the family members, such services nevertheless are covered because they

relate primarily to the management of the patient’s problems and not to the treatment of

the family member’s problems.

Cross-references:

The Medicare Benefit Policy Manual, Chapter 6, “Hospital Services Covered Under Part

B,Ӥ20.

The Medicare Claims Processing Manual, Chapter 12, “Physician/Practitioner Billing,”

§10.

The Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3,

“Deductibles, Coinsurance Amounts, and Payment Limitations,” §30.