Your Next Step

Before starting your SMAs, your must confirm with your colleagues who oversee billing and compliance that the codes that you plan to use will be approved by your clinic and/or health system and that your note templates comply with established guidelines. It is best to coordinate direct contact from your billing and compliance colleagues to insurance companies to ensure agreement about next steps. For your reference, here is the advice from the American College of Physicians: “ACP recommends that physicians inform each insurer in advance of their intent to begin furnishing group visits and how they plan to bill for them, thus giving the carrier an opportunity to communicate any concerns it may have or request an alternative billing arrangement… Before billing Medicare for group visits a physician should definitely contact the Medical Director of the Medicare carrier in that state to inquire how to bill for services provided to each Medicare beneficiary in a group setting.” Similarly, according to the American Academy of Family Physicians, for “compliance purposes, we recommend that you ask for [payer’s] instructions in writing and keep them on file as you would any other advice from a payer.”

The widely accepted “best practice” for billing SMAs is to treat each individual patient “check-in” that takes place during the SMA as a standard 1-1 follow-up visit. As a result, to meet standard billing requirements for the most commonly used billing codes for 1-1 follow-up visits (i.e., 99212, 99213, and 99214; when appropriate based on Medical Decision Making criteria) is to ensure that:

1. Every patient receives individualized care from the billing provider during the SMA that is

2. Documented in the note in the same way as a traditional 1-1 follow-up visit focused on Medical Decision Making criteria

These are based on recommendations from the American Academy of Family Physicians and American College of Physicians as well as the experience of many clinicians and health systems. Said another way, here’s the guidance from the American College of Physicians: “Because group visits are relatively unusual, no nationally accepted standard has yet emerged for billing them, and there is no special code for standard group visits. Acceptable billing thus varies both geographically and among different carriers. In cases where carriers have yet to adopt policies on group visit billing, the practice may be able to gain acceptance of its own proposed methodology - usually billing for each patient individually based on the services documented in the chart just as though the patient had been seen separately.”

Publicly-available resources from Kaiser Permanente and BlueCross BlueShield of North Carolina also supports this approach to documentation and billing.

Individualized Care

Because E/M codes that were developed for 1-on-1 care are typically used in SMAs, it is essential to ensure that you are billing for individualized care within a group context. That is, the decisions regarding data interpretation and/or treatment plans (see table below) should result from an individualized conversation that you have with a patient within the SMA. The outcome of this conversation can then be used in your note as the patient-specific plan for that visit. Although you can comment on any educational or experiential components of your SMA in your note, it is best practice to document patient-specific data interpretation and/or treatment plans to ensure that the E/M code aligns with the individualized care that you are providing to each patient.

Medical Decision Making

Unlike 1-on-1 visits that can be billed based on time, SMAs can only be billed based on Medical Decision Making, which is defined by the American Medical Association (see table below). These recommendations apply to all insurances, including Medicare and Medicaid, which routinely reimburse for SMAs. Although there is no national policy for insurance reimbursement of SMAs, many people point to the published guidance from Blue Cross North Carolina as precedent.

To orient yourself to the table below, which is your key to billing for SMAs, take note in the top left that billing for Medical Decision Making requires “2 out of 3” “Elements” - meaning, you need to satisfy requirements in 2 of the 3 columns on the right. Typically, 99213 codes can be used for SMAs focused on 1) “1 stable chronic illness” with 2) “low risk of morbidity from additional diagnostic testing or treatment,” referring to behavior changes as Lifestyle Medicine-focused treatments. Similarly, 99214 codes can be used for SMAs focused on 1) “2 or more stable chronic illnesses” with 2) either moderate “amount and/or complexity of data to be reviewed and analyzed” (e.g., independent interpretation of tests) or “moderate risk of morbidity from additional additional diagnostic testing or treatment” (e.g., prescription drug management).