Medical Coding for Group Visits

Many physicians are interested in providing group medical visits. Whether the drop-in group medical appointment (DIGMA), chronic care health clinic (CCHC), or other model is delivered, the coding and billing of these services raise questions about codes and payment policies.

While past instruction on coding for group visits often indicated that physicians should report code 99499 for unlisted evaluation and management services, using this code requires that documentation is sent with the claim to identify the service(s) provided and leaves valuing of the service in the hands of the payer.

It is important to note that no official payment or coding rules have been published by Medicare. However, the question of “the most appropriate CPT code to submit when billing for a documented face-to-face evaluation and management (E/M) service performed in the course of a shared medical appointment, the context of which is educational”, was sent to the Centers for Medicare and Medicaid Services (CMS) by the American Academy of Family Practitioners (AAFP) with a request for an official response. The request further clarified, “In other words, is Medicare payment for CPT code 99213, or other similar evaluation and management codes, dependent upon the service being provided in a private exam room or can these codes be billed if the identical service is provided in front of other patients in the course of a shared medical appointment?”

The response from CMS was, “…under existing CPT codes and Medicare rules, a physician could furnish a medically necessary face-to-face E/M visit (CPT code 99213 or similar code depending on the level of complexity) to a patient that is observed by other patients. From a payment perspective, there is no prohibition on group members observing while a physician provides a service to another beneficiary.” The letter went on to state that any activities of the group (including group counseling activities) should not impact the level of code reported for the individual patient.

There are five established patient E&M codes that represent different levels of care; the higher the last digit, the more complex the encounter and thus the higher the reimbursement rate: 99211, 99212, 99213, 99214, and 99215. Providers typically bill 99213, 99214, or 99215 for each patient in an SMA, representing individual visits for established patients with a physician or qualified non-physician practitioner.

It is important to note that providers’ documentation of these encounters must match the level of the E&M code used; thus, each patient care encounter in the SMA is to be viewed as a unique procedure that requires specific and detailed documentation. To improve the efficiency of this documentation, scribes (e.g., medical assistants) are often used to document providers’ care on a concurrent basis in the SMA. Charting in an electronic medical record during the visit is another way to optimize the face-to-face time with each patient.

Providers may not select an E&M code based solely on the time spent with each patient. The length of the visit can be the criterion for code selection only when counseling or coordination of care accounts for ≥ 50% of the time spent with a patient. In an SMA, the service delivered by a provider is medical E&M, not counseling or coordination of care.

Some private payers, such as Anthem BC/BS, have instructed physicians to bill an office visit (99201-99215) based on the entire group visit. For compliance purposes, we recommend that you ask for these instructions in writing and keep them on file as you would any other advice from a payer.

Where each individual patient is provided a medically necessary, one-on-one encounter, in addition to the time in the group discussions, there should be no problem in billing for the visit based solely on the documented services provided in a direct one-on-one encounter.

If your group visits include the services of nutritionists or a behavioral health specialist, contact payers to determine if that portion of the group visit can be directly billed by the non-physician provider. This typically would include codes for medical nutrition therapy (97804) or health and behavior intervention (96153).

Other codes that may be applicable are the codes for education and training for patient self-management involving a standardized curriculum (98961-98962). Neither these codes nor medical nutrition or behavioral health therapy is billed by physicians. Physicians must use evaluation and management codes to report these services.

Code 99078 describes physician educational services in a group. Again, it is necessary to contact the payer to verify that coverage of this service is a payable benefit.

As with many services, coding for group visits requires that billing and coding staff do preliminary work with payers to identify desired coding applications.


Coding for Group Visits

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