Coding for Group Visits:
The Rhode Island Experience
Be open and transparent with insurance companies as to your insurors. At a Rhode Island Academy of Family Physicians, Arnold Goldberg, MD presented group medical visit coding and billing issues to public and private insurers and gained approval of using E&M codes. Although it may differ from state to state, having an open dialogue with insurors, informs them of the process and positive outcomes (see outcomes section attached).
Document a 1:1 interaction medical encounter, given you are seeing each person for a period of time to address medical issues: E&M codes (99213, 99214) can be used. These E&M codes are used by most programs conducting group medical visits in the north east US.
The state of Florida has established a master diabetes program, under the direction of Ed Shahady, MD. This includes training practicing physicians in group medical visits. The Florida Academy of Family Physicians has challenged their members to conduct at least one group medical visit per month by the year 2010. Listed below is their documentation recommendations.
A 99213 requires a chief complaint, 1 to 3 questions about diabetes (frequency and values of self-monitored blood sugars, vision, feet, exercise, diet etc), 1 ROS (review of systems) question, and low complexity care of deabetes, an assessment of controlled diabetes, and a plan that deals with the diabetes. Use a controlled diabetes ICD 9 code like 250.00 for type 2 controlled or 250.01 for type I controlled. The fifth digit indicates control and the fourth digit indicates comlications. If they are controlled but a complication, like renal disease, is not controlled, you should be able to code a 99214. You do not need to do any exam, but document the above items like the CC, usual diabetes questions, etc... The patient questionnaire documents the answers (see patient questionnaire). Document any significant answers.
Most of your patients ina group visit should be the ones that are the most difficult to control, have HbA1c's greater than 6.5, LCL less than 100, or blood pressure greater than 130/80. The ICD 9 fifth digit would be 2 or 3 if one of these values is not controlled. Remember to document all of these values. The fourth digit indicates compleactions. An example would be server diabetic neuropathy (fourth digit of 6) in a type 2 in control would be 250.60. If the patient is not controlled (HbA1c is greater than 6.5), the ICD 9 codew would be a 250.62.
A 99214 requires four questions related to their diabetes, 2 ROS questions, and one questions about either past medical history and/or social history. Include in the documemtation evidence that the patient is an uncontrolled diabetic not at target and how you will attempt to bring the patient into control. Documenting the attempt to bring the patient into control satisfies the moderate complexity reuqirement. Other documentation that indicates uncontrolled and moderate complexity includes some of the following:
1. Numbers that are out of control, such as HbA1c, LCL, B/P
2. Patient not obtaining eye consult or other consults
3. Complications are present, such as retinopathy (dilated eye exam positive), neuropathy (monofilament or vibratory sese decreased), nephropathy (creatinine increased), angina, TIA, stroke, chest pain, MI, hypertension
4. Modifications in care, such as more exercise, diet, eye exam, urine testing, etc.
5. Increasing a medication dosage, starting a new med, or suggestions for increased adherence to medications or lifestyle.
6. Discussion of side effects of medications like statins, review of drug interactions (note where you found the information, ie Epocrates).
7. Advice and discussion of how to adhere to lifestyle changes.
For gropu visits yuou do not need to do any exam other than vital signs to code a 99213 or 99214 for established patients as long as you have satisfied the history and level of complexity requirements as indicated above.
Be sure your ICD 9 code reflects the level of control, type of diabetes and any complications.
Summary of ICD-9 Codes in Diabetes
A. 5th digit 250.XX indicates the type of diabetes and level of control:
a. 250.X0 indicates Type 2 controlled
b. 250.X1 indicates Type 1 controlled
c. 250.X2 indicates Type 2 not controlled
d. 250.X3 indicates Type 1 not controlled
B. 4th digit 250.XX indicates the complications
a. 250.0X indicates no complications
b. 250.4X indicates renal complications
c. 250.5X inidcates eye complications
c. 250.6X indicates neurological complications (Shahady, 2006).
AAFP recommends that billing/coding staff do preliminary work with payers to identify desired coding applications, recommending that these instructions be procured in writing and kept on file. They suggest using a one-on-one encounter code: 99499 for unlisted evaluation and management services, along with additional codes if a non-medical provider is included in the services.
"Where each individual patient is provided a one-on-one encounter 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." (AAFP, 2007)
Shahady, Edward. Enhanced outpatient care for diabetes througth the use of a disease regsitry and group visit. Conference proceedings: Society of Teachers of Family Medicine Annual Conference proceedings. April, 2006.