Bill Dacey

 I run a lipid clinic and believe I have found a way to treat patients with the same illness efficiently and effectively. I have about 20 patients come to our clinic conference center in the early evening. My nurse checks vitals on them all, we have all 20 charts available, and she goes over their recent labs with them. I lecture them on diet, health maintenance, and medication.

I make a note in each chart that supports a 99213 based on history and exam. One consultant told me this may not be proper. Is there a problem with this approach?

 Yes, there is a problem here. It is certainly efficient and likely a good use of your time to deal with patients collectively in this fashion. However, billing 99213 individually to patients for services that are provided to a group would be considered fraud. I personally checked with one of the largest Medicare carriers in the country, and they were not pleased with the prospect you outline. When I indicated that by looking at your individual note, they (Medicare) would likely not be able to tell that the services were provided in a group setting, the Medicare representative was more than unhappy.

There are codes for services in a group setting, codes 99411 and 99412, and they pay significantly less than a 99213 - but they are the correct code. The codes represent 30 minutes and 60 minutes of education, respectively.

If you take an unadjusted fee schedule amount of roughly $40 payment for a 99213 - multiplied by your twenty patients - that’s $800 for the hour or two worth of work - not exactly the going Medicare rate for noncritical E&M. This would not be OK with them.

The work RVU for 99213 in 2010 is .97. The work RVU for 99411 is .15 and for 99412 is .25. Even the one hour code is only a fourth of the 99213 rate. As you can see, these are different enough to raise concern.

I have heard of groups billing similar events with a 99211. It sometimes takes the form of a group prenatal session, a blood pressure clinic, etc. But they aren’t individual visits.

When you read the description for a 99213 in the CPT Manual, it refers to “a visit for the evaluation and management of an established patient.” It doesn’t say “individual,” but it doesn’t say “patient(s)” either. The 99213 is for an individual visit - don’t test that one.

is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@cmpmedica.com.

This question originally appeared in the June 2010 issue of 

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Billing 99213 for individual patients seen together in a group visit is fraud.

Group Visit Codes

If an advanced registered nurse practitioner sees a patient for an inpatient consult and dictates: "See H&P notes and labs in chart" in her exam section, then only notes vitals and mental status exam, can I give her credit for work in the exam piece in the H&P when it was completed by another physician?

Is she billing a consult separate from the other physician? Or are they collaborating on the same day with one charge going out? If it's the former, and the other doc is using that H&P as part of his or her admit or other bill, then she can't use it. The work involved in performing the physical exam or any other part of a given visit belongs to that visit and its associated code, charge, and payment.

You can't "borrow" work that has been previously performed, claimed, and paid for and include it in a new code you are presenting for payment - it's double dipping.

If it's the latter case, and these two providers are collaborating with one bill going out, then reference Medicare's consult guidelines: "Carriers shall instruct physicians and qualified NPPs that a consultation service shall not be performed as a split/shared evaluation and management service."

This question originally appeared in the February 2010 issue of

Medicare says no split/shared evaluation for a consult.

Author | Bill Dacey

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