Group Visit Codes

December 8, 2010

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

Question: 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?

Answer: 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.

Bill Dacey, CPC, MBA, MHA, 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 Physicians Practice.