Coding Tip: Billing an Office Visit Without the Patient Present

Can you bill an office visit when the family member attends the appointment in place of the patient? 

Under CPT guidelines, an office visit may be billable when a family member or caregiver attends in place of the patient, as long as the patient is already established and documentation requirements are met. 

Per 2025 E/M guidelines, time-based coding can apply to visits involving the physician and/or family/caregiver, not just the patient. Further instructions state that it includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician on the day of the encounter. 

Additional tips and guidance:

• Confirm Patient Status First: Before billing, verify that the patient is already established in your practice. New patient visits cannot be billed if the patient is not present, even if a family member or caregiver is.
  
• Thoroughly Document : Ensure documentation clearly identifies that the patient was not present, the reason for their absence, the medical necessity of the visit, the topics discussed with the caregiver/family member, time spent (if using time-based coding)
  
• Use Appropriate E/M Code Level : When time-based coding is used, make sure the total time spent on the date of service is documented, including  time spent with family/caregiver and relevant non-face-to-face activities, such as reviewing records, documenting in the EHR, or ordering tests
  

Check for Payer-Specific Limits : Some payers may not allow billing if the patient is not physically present, even if CPT supports it. Medicare, for instance, has historically had stricter interpretations. Always verify policy-specific rules.



Melanie Perrault, RHIA, CDIP, CCS 

Senior Consultant, Audit 

Melanie Perrault is a Senior Consultant in Quality at UASI, with extensive expertise in inpatient coding, CDI, and documentation integrity. She brings a strong educator’s mindset to her coding tips, helping coders and CDI teams strengthen clinical clarity, accuracy, and audit-ready compliance. 

Works Cited:

CPT Assistant. (2013, March). [Article]. CPT Assistant, 23(3), 13.

*Note: Always review payer-specific guidance, as interpretations may differ from AMA recommendations