Coding for Group Visits

Many physicians are now becoming 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 remain somewhat problematic.

In 2001, the AMA CPT Editorial Panel, who decide the need for new or revised CPT codes, determined that group visits should be reported with 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.

No official payment or coding rules have been established by Medicare. However, a standard answer to the question is given by Centers for Medicare and Medicaid Services (CMS) physician payment policy staff as follows: "Only one physician may bill for a face-to-face encounter with one patient in an individual encounter and one instance of time."

We have been told by members who provide group visits that some payers have instructed them 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 one-on-one encounter (outside the group setting) in addition to the time in the group, there should be no problem in billing for the visit based solely on the time spent one-on-one.

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 are 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 is complicated and requires that billing/ coding staff do preliminary work with payers to identify desired coding applications.