As our health care system continues to evolve in this era of reduced resources, there is an increasing demand for the delivery of high-quality, high-value, and low-cost care with increased patient access. One idea that has recently gained more significant attention is that of the shared medical appointment (SMA).¹ In an SMA, multiple patients are seen both as a group and individually, often for follow-up or routine care, or to receive counseling on a specific disease state. SMAs have been proposed as a way to increase patient access to health care while potentially reducing overall healthcare costs.^1,2 

There are multiple SMA models, including, but not limited to, drop-in group medical appointments, chronic care health clinics, and cooperative health care clinics, the details of which are beyond the scope of this article. SMAs have been shown to have potential benefits when used in a number of medical specialties,^3-5 including dermatology,⁶ weight loss,⁷ and urology.⁸ Most insurers recognize the potential benefits of SMAs and have determined that the services are reimbursable, although no specific guidelines have been released by Centers for Medicare & Medicaid Services. Great care must be taken for accurate reimbursement. 

Pros and Cons

SMAs have many potential advantages for both patients and health care providers. If run correctly, an increased number of patients can be provided timely access to care and information. The provider can address a group of patients as a whole instead of repeating the same information in individual patient visits, increasing the overall productivity of the health care team. The group portion may include providers from multiple but overlapping disciplines to allow a greater breadth of information than might be achieved by a single practitioner. For example, a kidney stone clinic shared appointment may include a urologist, nephrologist, nutritionist, and/or other complementary health care providers. Patients may feel a kinship with the other patients and share their mutual experiences, which may ultimately increase patient satisfaction. 

However, SMAs may have potential disadvantages. It is important that the appointments be well designed, adequately supported, and properly run. Whereas a urologist might discuss multiple urologic conditions with an individual patient on a typical visit, an SMA may be limited to one topic. There is potential for privacy concerns, so it is important that those agreeing to participate understand that it is voluntary and should sign a confidentiality waiver and Health Insurance Portability and Accountability Act (HIPAA) disclosure form. There are areas of potential abuse, such as providers attempting to gain economic advantage by providing suboptimal resources or facilities, attempting to extract more from group visits than is commensurate with good care, forcing patients into the SMA for economic reasons, and not allowing adequate time for individual patient examinations and discussions.⁸ 

What Are Potential Applications in Urology?

Many urologic conditions would fit well in a properly run SMA. SMAs have already proven to be efficacious in counseling for kidney stone prevention,⁹ prostate cancer, erectile dysfunction, benign prostatic hyperplasia, incontinence, neurogenic bladder, and chronic discomfort syndromes.¹⁰ It is of utmost importance to have a well-designed, adequately supported meeting to achieve the highest likelihood of success. 

How To Code

Currently, it is best to choose typical outpatient Evaluation and Management codes for each individual patient, based upon payor rules, patient status, and level of service provided (99211-99215, 99201-99205, 99241-99245). Some have proposed using code 99499, which describes an unlisted evaluation and management service. Unfortunately, this is an unlisted code, and therefore documentation of the service must be submitted with the claim along with a similarly valued code for benchmarking reimbursement; yet ultimately, reimbursement will be up to the individual payer. If other services are rendered, such as a nutritionist or other therapist, these may also be billable services. Appropriate copayments should be collected based upon payor rules. Prior authorization should be obtained if necessary. In the future, a specific code or modifier to be applied to individuals attending group visits may be created, but is not available at the time of publication. 

No official payment or coding rules have been published by Medicare for SMAs. This was confirmed, in a sense, by Centers for Medicare and Medicaid Services (CMS) when the American Academy of Family Physicians (AAFP) asked the question “What is the most appropriate CPT code to submit when billing for a documented face-to-face evaluation and management (E/M) service performed in the course of a shared medical appointment, the context of which is educational?” The authors further clarified, “In other words, is Medicare payment for CPT code 99213, or other similar evaluation and management codes, dependent upon the service being provided in a private exam room or can these codes be billed if the identical service is provided in front of other patients in the course of a shared medical appointment?” According to the AAFP Web site, the response from CMS was, “...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.” The letter went on to state that any activities of the group including group counseling activities should not impact the level of code reported for the individual patient.¹¹ 

CMS therefore appears to have no problems with others observing an interaction or listening to or participating in a shared discussion; however, neither the time component nor the content discussed in the shared visit should be used to for billing purposes, if billing on time of medical decision-making complexity. This discussion can be and should be noted on the listener’s chart. The shared or observed portion is important for efficiency of the provider (not needing to repeat the same information to each individual), and allows for a broader understanding and more depth to the discussion than might be possible from individual appointments. Ultimately, however, each individual patient should have recorded his or her own medical necessity, appropriate history of present illness, past history and review of systems, physical examination (if pertinent for established patients), and medical decision making, with the appropriate level of service chosen based upon payor rules. The shared discussion time should not be included if billing based upon time, because time is based upon face-to-face counseling and coordinating care to the patients themselves, not to the listeners. It is advisable to not routinely charge for such an appointment based on time unless the individual face-to-face services themselves are extensive. 

Private payors may have different rules than Medicare, so it is important to follow their rules, and to get their rules in writing. Some private payors have instructed physicians to bill an office visit based on the entire group visit. Blue Cross Blue Shield of North Carolina’s Web site states that group visits are covered if specific criteria are met, including seeing only established patients, that the visit be disease or condition specific, that attendance is voluntary and adequate facilities are provided, and that the individual and group interactions are documented as part of the patient’s medical records. Circumstances in which group visits are not covered include new patients, if there is not a physician in attendance in the group portion, if there is inadequate time or staffing or facilities, and if the patient is not allowed to have one-on-one time with the physician.¹² 

There are other potentially billable E/M codes in a shared setting. Code 99089 describes Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions). However, this code currently has zero Relative Value Units (RVUs) associated with it, so it would be advisable to contact the payor to verify coverage of this service before providing the service; otherwise one runs the risk of not being reimbursed. For nutrition therapy, there is code 97804, which describes Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes (around 0.45 RVUs), and the G-code G0271 Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes (around 0.45 RVUs but for a benchmark, some have seen approximately $40 in reimbursement). Finally, code 90853 describes group psychotherapy (other than with a multiple-family group) and has around 0.75 RVUs. 

Conclusions

SMAs have many potential applications to urologic practice. If properly planned with adequate facilities provided, SMAs may ultimately increase efficiency, patient access to high-quality care, and patient satisfaction with increased health outcomes. Coding and billing for services provided currently should be on an individual basis, following local payor rules and regulations, and require an understanding of the need for individual portions and understanding the documentation and coding guidelines.   

References

1. Noffsinger EB. Physicals shared medical appointments: a revolutionary access solution. Group Practice Journal. Jan 2002;1-9. 
2. Rhee E, Baum N. The shared medical appointment: a proposed model of medical appointments. J Med Pract Manage. 2013;29:172-175. 
3. Weinger K. Group medical appointments in diabetes care: is there a future? Diabetes Spectrum. 2003;16:104-107. 
4. Edelman D, Fredrickson SK, Melnyk SD, et al. Medical clinics versus usual care for patients with both diabetes and hypertension. Ann Intern Med. 2010;152:
   689-696. 
5. Kirsh S, Watts S, Pascuzzi K, et al. Shared medical ­appointments based on the chronic care model: a quality improvement project to address the ­challenges of patients with diabetes with high cardiovascular risk. Qual Saf Health Care. 2007;16:349-353. 
6. Sidorsky T, Huang Z, Dinulos JG. A business case for shared medical appointments in dermatology: improving access and the bottom line. Arch Dermatol. 2010;146:374-381. 
7. Palaniappan, LP, Muzaffar AL, Wang EJ, et al. Shared medical appointments: promoting weight loss in a clinical setting. J Am Board Fam Med. 2011;24:326-328.
8. Noffsinger EB, Scott JC. Potential abuses of group visits. The Permanente Journal. Spring 2000. http://xnet.kp.org/permanentejournal/spring00pj/
   abuses.html. Accessed July 23, 2014.
9. Jhagroo RA, Nakada SY, Penniston KL. Shared medical appointments for patients with kidney stones new to medical management decrease appointment wait time and increase patient knowledge. J Urol. 2013;190:1778-1784. 
10. Fletcher SG, Clark SJ, Overstreet DL, Steers WD. An improved approach to followup care for the urological patient: drop-in group medical appointments. J Urol. 2006;176:1122-1126.
11. Coding for Group Visits. American Academy of Family Physicians Web site. www.aafp.org/­practice-management/payment/coding/group-visits.html. ­Accessed July 23, 2014.
12. Corporate Reimbursement Policy. Group Visit (Shared Medical Appointment) Guidelines. www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/group_visit_shared_medical_appointment_­guidelines.pdf. Accessed July 23, 2014.