LCD/NCD Portal

NCD70.1

 

CONSULTATIONS WITH A BENEFICIARY'S FAMILY AND ASSOCIATES

 

Effective Date of this Version

• This is a longstanding national coverage determination.

• The effective date of this version has not been posted.

 

Benefit Category

• Physicians' Services.

• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

 

Indications and Limitations of Coverage

• In certain types of medical conditions, including when a patient is withdrawn and uncommunicative due to a mental disorder or comatose, the physician may contact relatives and close associates to secure background information to assist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.

o 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.

o 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.

o In some cases, the physician will provide counseling to members of the household.

o Family counseling services are covered only where the primary purpose of such counseling is the treatment of the patient's condition.

o For example, two situations where family counseling services would be appropriate are as follows:

 Where there is a need to observe the patient's interaction with family members.

 Where there is a need to assess the capability of and assist the family members in aiding in the management of the patient.

o 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.

o 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 Reference

Medicare Benefit Policy Manual, Chapter 6,

 

Medicare NCD Link