Medical coding for group visits
The benefits of group visits are clear. How to bill for them may be less obvious. Here’s what you should know.
Medicare has not published official rules on billing for group visits, and private payer instructions vary.
Group visit codes and considerations
| Potential group visit code | Considerations |
| 99213 (or similar E/M codes) | Activities of the group (including group counseling activities) should not impact the level of code reported for the individual patient. |
| 99201-99215 (office visit) | Contact payer for instructions. |
| 97804 (nutritional therapy) | Cannot be billed by a physician. |
| 96153 (behavior intervention) | Cannot be billed by a physician. |
| 98961-98962 (education and training for patient self-management involving a standardized curriculum) | Cannot be billed by a physician. |
| 99078 (physician educational services as a group) | Contact payer for instructions. |
| 99499 (unlisted E/M services) | Leaves valuing of the service in the hands of the payer. Documentation must be sent with claim to identify services provided. |
What are group visits?
Group visits, or shared medical appointments, provide a secure, interactive setting in which patients have improved access to their physicians, the benefit of counseling with additional members of a health care team (behaviorist, nutritionist, health educator, etc.) and the opportunity to share experiences and advice with others. They are used for follow-up care or management of chronic conditions.
Benefits of group visits can include:
- Increased physician productivity
- Decrease in a practice’s cost per visit
- Reduced scheduling backlogs
- Increased patient compliance and satisfaction
- Improved care delivery
The structure of your visits might vary based on condition.
Medicare’s position on group visits
Medicare has not published official payment or coding rules regarding group visits. However, CMS has previously stated:
- 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 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.
- Any activities of the group (including group counseling) should not impact the level of code reported for an individual patient
Private payer variability
Some private payers instruct physicians to bill an office visit (99201-99215) based on the entire group visit. For compliance purposes, ask for instructions in writing and keep them on file as you would any other advice from a payer.
When 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.
Billing for non-physician services
- Codes for nutrition therapy (97804) and behavior intervention (96153): 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.
- Patient self-management education codes (98961–98962): Other codes that may be applicable are the codes for education and training for patient self-management involving a standardized curriculum (98961-98962). These codes are not billed by physicians. Physicians must use E/M codes to report these services.
Learn more about billing and coding for non-physician services.
Documentation tips for compliance
- Individually evaluate and manage each patient, as well as counseling with the group as a whole.
- Document shared medical appointments in each participating patient’s medical record.
- Reflect the individual services provided to each patient in documentation, as well as the services provided to the group as a whole at each encounter.