How to bill for shared medical appointments


Other questions addressed in this installment of "Coding Q&A" include understanding the Physician Quality Reporting System and avoiding being denied payment for lab tests based on medical necessity.

I was at a conference recently where shared medical appointments (SMA) were discussed. These may be appropriate for my practice. It is my understanding that the time spent with the group is not counted in the evaluation and management service, but that the time spent with each individual patient or the elements documented for each patient encounter can be counted toward the evaluation and management service level. Is this correct, and is there anything else I should know about these visit types?

The SMA is an interesting topic, not only for urology but for other specialties as well. The concept has even received some attention from payers as a covered service. Of course, you will need to double check with each payer as to whether the concept is acceptable.

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In researching your question, we have come across a number of different names for the SMA, the most common being the DIGMA (drop-in group medical appointment), for those established patients with a common diagnosis needing a comprehensive approach to follow-up care, and the CHCC (cooperative health care clinic), for groups of patients with a common chronic disease seeking both information and community support for their disease.

Regardless of the name, SMAs follow a similar format and, at present, should be charged in a similar manner.

In most cases, the SMA starts with an update to each patient’s medical history. This can be undertaken in the group setting or prior to bringing the group together. The second portion of the visit is undertaken as a group as the disease is discussed. Often, individual issues are brought up in front of the group with participation from the provider and other patients. Examinations, if required, can be provided in a separate room for patient comfort.


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Updates to prescriptions or adjustments to treatment can be made for individual patients in front of the group or as the group is dispersed. Each patient chart is updated separately, often with the assistance of a scribe or other staff member. The patient is charged for the service as if a one-on-one established patient office visit has been provided. Co-payments, co-insurance, and deductible payments as well as separate insurance coverage are collected at time of visit or through the standard billing process.

The question of correct reporting, documentation, and rules surrounding reimbursement of these types of visits is multifaceted. The American Academy of Family Physicians requested an opinion of the Centers for Medicare & Medicaid Services with regard to these types of visits. Rather than asking whether billing for services such as these are covered, the AAFP wisely asked CMS whether there is a rule or restriction from Medicare that would require that a standard office visit be reported only if the service is provided in a private examination room or in the absence of other patients. CMS’s response was that there is no Medicare requirement that services be provided in private or only with medical personnel present as long as the patient agrees to the circumstances of the visit through signed consent.

Further, a number of private payer organizations have indicated that such visits are payable as long as some general criteria are met. Common to most of these policies are the following:

  • The situation is voluntary.

  • Appropriate consent is obtained in writing.

  • The visit is intended as a care-giving visit (not strictly educational).

  • The visit is interactive and intended to provide the patient with additional self-care instruction.

  • The session is designed to be efficient and effective for provider and patient.

If followed as listed above, reporting under established patient office visit codes 99211-99215 is appropriate and should be based on the chart notes for each patient. Charges for each patient visit should be based on the elements documented in each patient’s chart.

Billing on time spent face to face will need to be treated differently, as the patient care provided in the group is not to be counted in the overall time spent; therefore, time-based visits under these circumstances should only count time spent counseling each patient separately. This may be appropriate in some circumstances; however, it defeats the purpose of the intended efficient nature of the SMA. We recommend that patients requiring extensive separate counseling be scheduled for a separate visit.

The growing popularity of the SMA may be attributed to many factors. The positive response many have gotten from patients is a big driver. The group serves as both a support group and a source of questions and answers beyond patients’ own knowledge. With a shortage of health care providers in some areas and a growing decrease in available providers, we would expect the SMA to grow in popularity in the next few years. As with all services that seem to save time and provide physicians with a way to expand services at lower cost, we expect that Medicare and other payers will address payment policies, perhaps leading to new coding requirements or new codes. So stay tuned.


Next: Help in understanding PQRS



Where can I find help in understanding the Physician Quality Reporting System (PQRS)? We do report some measures and I have told patients to stop smoking, lose weight, etc. We do not have an EHR.

The problem many physicians have is trying to place PQRS into an understanding that includes logic behind it and to perceive its value. The logic and the value may make sense to the statisticians, but it's hard for physicians to comprehend. In actuality, it’s not that complicated. It’s just a set of rules that you have to read, interpret, and follow. At times, doctors make this stuff more complicated than it really is.

We would suggest that you read the updated regulations and review the AUA tutorial, not with the idea of understanding all of it but just to pick out the "to dos." If it still looks like Greek, then we recommend hiring a consultant to assist in setting up a protocol to simplify the process. There are many consultants locally, or you can contact the AUA, Physician Reimbursement Systems, etc.

Further statistics show that claims-based reporting is the most difficult of any method for reporting PQRS. There are several methods accepted for reporting PQRS measures other than claims-based reporting. Without an EHR, the most successful measure has been the use of a data registry. We would recommend looking carefully at your practice after reading the options and choosing a method of reporting that is best suited to your practice. Once you have made your decision, you will need to implement the practice’s clinical and documentation protocols to meet the requirements of each measure selected.


Next: Denials based on medical necessity



I have just received a letter from a payer (probably a Recovery Audit Contractor audit) stating that a number of my lab tests have been denied, based on medical necessity. What gives the payer the right to make the decision about what is medically necessary for my patient?

The short answer is "the purse strings.” They have the money and set the rules. That doesn’t answer your question of what gives the payer the “right," and neither can we. However, we will give you a brief answer on how to avoid the take backs based on how they do it.

First and foremost, your documentation must show the reason you are ordering that test on that day. In addition, the test should be considered necessary under the current circumstances for that patient based on clinical practice guidelines, national payment guidelines, and/or local medical decisions, if available. Finally, the test must be covered by that patient’s contract with the payer.

That's the short answer. If you need more a more detailed explanation, see our previous articles at or visit for our webinar and seminar archives.UT

Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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