Corporate Compliance

Be careful of compliance concerns related to group visits

Compliance Monitor, December 9, 2005

Q: Can you tell me how to bill for group medical visits? This issue has come up recently and any information would be helpful. Thank you.

A: Coordinated health care clinics (CCHCs) are one of several innovative physician practice models general medicine and family practice communities have begun to explore in order to manage burgeoning patient loads. CCHCs offer the opportunity for physicians and patients to spend time together in small, collaborative groups, typically focusing on specific high-maintenance diseases (e.g. hypertension or diabetes). Led by the physician, patients interact with the provider and each other, offering the opportunity for support and idea sharing in addition to clinical evaluation.

Based on recent studies, this format has been successful in improving disease-specific outcomes, general patient health, and patient satisfaction. Coding and billing for the service, however, continue to be elusive.

Technically, the physician spends time with each patient, obtaining a history of present illness, performing physical examinations, partaking in medical decision making, answering patient-specific questions, and educating the patient about their health. Documentation of these items for each patient still occur as though he or she were seen in a standard, one-to-one office visit. It appears, then, that if the physician has the documentation to support the individual evaluation and management, counseling, or educational service, it should be irrelevant that the service was delivered in a two-hour group appointment versus a 15-minute individual encounter.

Unfortunately, CPT/HCPCS does not address this service model specifically, and the corresponding codes are still defined with the original intent of single-patient encounters. The CPT Editorial Panel currently advises to code and bill the encounters as 99499 unlisted evaluation and management service. Using the existing one-to-one CPT/HCPCS codes for E/M, counseling, or education services when provided in a group setting may be construed as misuse, abuse, or fraud, leaving the organization open to compliance sanctions and civil liabilities.

So what can your organization do?

Look (or call) before you leap. Before offering any new service, always check with your most common insurance plans regarding coverage and reimbursement issues. If the payer agrees to reimburse group visits using current E/M codes, obtain the direction in writing from the payer and keep it as part of your coding and billing policy manual. It is legitimate to use codes as required by a payer, but never do so based on a verbal instruction alone. If the payer refuses to put the policy in writing, rest assured they know it is an inappropriate practice.

Bill Medicare. Medicare payments and coverage decisions develop from claim submission data (and non-governmental payers often take their cues from Medicare), so even if Medicare does not currently pay for a service, they are monitoring and evaluating line-item level activity for future development. Call your local carrier for advice on their current policies for this service.

Petition for new CPT codes for the service from AMA. The American Medical Association accepts applications on a continual basis from individuals and organizations seeking new or revised CPT/HCPCS codes-their quarterly agendas are full of presenters discussing new items for category I, II, and III codes. Visit for more information.

Thank you to Elizabeth Stewart, RHIA, CHAM, vice president and managing partner of The Stewart Group LLC in Akron, OH for providing this answer.

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