What patients with diabetes want and need for the successful management of their disease is exactly what shared medical appointments (SMAs) can provide. Topping the list are increased access to care, quality time with the physician, an active role in medical and lifestyle decision-making, their unique needs individually addressed in a timely manner, and encouragement and support from other people with diabetes. For health care professionals, SMAs are a cost-effective way to provide both diabetes medical management and self-care education in the same visit in a manner consistent with highly interactive patient-centered care. This article offers an overview of Medicare and private insurance reimbursement for SMAs.
In today's highly competitive and challenging economic environment, physicians, health care professionals, and health care organizations are facing patient and payer demands for quality, access, service, and patient satisfaction with insufficient resources and ever-increasing workloads. It is more difficult than ever to meet these demands in a profitable way to sustain the practice entity. The old adage “do more with less” is now a reality.
The current U.S. health care system is beginning to shift to more cost-effective solutions in delivering quality patient care to meet these increasing demands. Ambulatory shared medical appointments (SMAs), also called group medical visits, have been recognized as an alternative to traditional one-on-one patient office visits. SMAs are designed to 1) maximize the use of limited resources, 2) better manage patient care workload, 3) increase productivity without increasing work hours, 4) manage busy physician practices more efficiently, 5) effectively address the ongoing needs of patients with chronic conditions such as diabetes, 6) increase face-to-face time between providers and patients with chronic conditions, and 7) increase patients' involvement in their own care while improving patient satisfaction. For these reasons, providers are beginning to recognize the value of SMAs beyond the financial benefits.1–4
Brief Overview of SMAs
Patients in the same SMA generally share a common medical condition or chronic disease. SMAs have been used for medical management of chronic diseases such as type 2 diabetes, hypertension, asthma, and congestive heart failure. Patients may also benefit from SMAs for smoking cessation or the treatment of panic disorders. When homogenous patient groups share medical appointments, patient satisfaction, behavior goals, and clinical outcomes tend to improve.1–4 This is because patients “share and compare” common disease challenges (e.g., diet, medications, exercise, and stress) and, more importantly, solutions to these challenges. This caring and connecting bonds patients together, helping them achieve enhanced psychological and health benefits.
The perception of many patients is that they are receiving more time with their provider in an SMA, even though providers typically spend less individual time with patients in this format. The average time spent per patient is 5–8 minutes in an SMA compared to 15–20 minutes in a traditional one-on-one office visit.1,2,4,5 This phenomenon is the result of group homogeneity. When providers discuss treatment options for one patient's persistent hyperglycemia, other patients in the SMA who are experiencing the same issue may internalize the discussion and relate it to their own needs.
SMAs are typically 90–120 minutes in length and include established patients who are currently being seen by a physician or a qualified nonphysician practitioner (also called mid-level providers) such as a nurse practitioner, physician assistant, or clinical nurse specialists. Providers (physician or mid-level) often choose to furnish SMAs initially once per month for patients who are not at clinical targets and then quarterly for ongoing support.4,5 Some models return patients to routine care after they meet clinical targets.
Evaluation and management (E&M) visits with providers may be offered in a separate room or behind a privacy screen. However, many providers adhere to the original concept of the SMA: sharing individual patient medical encounters with the other patients in the group.1,2,4,5 Patients are required to sign a confidentiality statement before joining in an SMA in which they agree not to discuss what they have heard or seen during the appointment.
Group medical visits for patients with diabetes may consist of two distinct components: individual medical management and group diabetes self-management education/training (DSME/T) or group medical nutrition therapy (MNT). Group DSME/T instructors are typically registered nurses (RNs), registered dietitians (RDs), and/or pharmacists who may also be certified diabetes educators (CDEs); professionals from other disciplines may also teach. MNT is billable to Medicare Part B when provided by RDs or other qualified nutrition professionals.6 For Medicare billing of DSME/T, programs must have accreditation status by either the American Association of Diabetes Educators (AADE) or the American Diabetes Association (ADA).7 Medicare does not allow billing for both benefits on the same day, although some private payers do.
SMAs do not always include an education component, and some may provide nonbillable education. For example, a 30-minute foot care presentation provided by a podiatrist would not be considered billable education and would not allow a provider to increase the level of the E&M. In this SMA model, the provider would bill only for an individual, established-patient medical management encounter for each attendee. Billing Medicare for DSME/T using the procedure code G0109 (30 minutes of group DSME/T) for a podiatrist's presentation would be allowed if the following elements were in place: 1) the session was provided through an accredited DSME/T program curriculum within the practice entity, 2) the podiatrist was on the instructional staff of the accredited DSME/T program, 3) all the patients were enrolled in the program, 4) patients had not exceeded the utilization limit of the benefit, and 5) all other Medicare DSME/T coverage guidelines were met.
A key element to the financial success of SMAs from the providers' perspective is the implementation of accurate reimbursement procedures. SMAs are a more cost-effective care delivery model than traditional one-on-one provider appointments.1,2,4 Payers, including Medicare, now recognize the benefits of the group care approach. This has allowed providers to bill for individual E&M encounters furnished in this group format; thus, SMAs increase revenue capacity with less time on providers' part and without reducing the quality of care.5,8
For example, if there are 10 patients in an SMA that lasts for 2 hours, including 1 hour with a provider, the provider can bill for 10 individual follow-up E&M visits. If the fee is $100 per hour, the provider may bill for $1,000 (1 hour with each of the 10 patients). Compare that to seeing 10 patients one-on-one in a traditional office setting and spending about 20 minutes with each patient. It would take the provider more than 3 hours to bill for the same $1,000. In an SMA format, this 1 hour would translate to $17 per minute; the 3.3 hours in the office would translate to $5 per minute.
To maintain financial productivity, the number of patients seen in the SMA should justify the costs and effort associated with conducting the group visit. This is usually accomplished by setting the census at a level that roughly triples the number of patients a provider could see in the same amount of time in office visits. In other words, if a physician typically sees four patients in his or her office in 1 hour, an SMA should allow the physician to see ~12 patients in the same hour.
With private payers, it is important to address billing and any other system issues before starting an SMA program. Because of rapid changes in reimbursement from managed care organizations and government agencies, it is best to thoroughly explore all billing options. It is recommended that local insurers or contracted entities be contacted to identify any potential billing issues and to gain a clear understanding of the reimbursement policies and coverage guidelines involved in provision of SMAs.
Medicare Reimbursement for Services of Physicians or Qualified Nonphysician Practitioners in SMAs
It is important to note that at the time this article was written, Medicare had not issued any official payment or coding rules for SMAs.6 In one instance, a group of physicians contacted the Center for Medicare and Medicaid Services (CMS) asking for an official response regarding “the most appropriate Current Procedural Terminology (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.” They also asked, “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?”9
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.”9 The response also stated that any activities of the patient group, including group counseling activities, should not affect the level of the CPT code reported by the physician or mid-level practitioner for the individual patient.9 Therefore, the recommendation is that medically necessary visits by a physician or mid-level practitioner in an SMA may be billed the same as for a typical individual patient visit in an exam room based on the level of care delivered and documented in the patient's chart according to criteria for CPT code use.
There are five established patient E&M codes that represent different levels of care; the higher the last digit, the more complex the encounter and thus the higher the reimbursement rate: 99211, 99212, 99213, 99214, and 99215. Providers typically bill 99213, 99214, or 99215 (Table 1) for each patient in an SMA, representing individual visits for established patients with a physician or qualified nonphysician practitioner.
It is important to note that providers' documentation of these encounters must match the level of the E&M code used; thus, each patient care encounter in the SMA is to be viewed as a unique procedure that requires specific and detailed documentation. To improve the efficiency of this documentation, scribes (e.g., medical assistants) are often used to document providers' care on a concurrent basis in the SMA. Charting in an electronic medical record during the visit is another way to optimize the face-to-face time with each patient.
Providers may not select an E&M code based solely on the time spent with each patient. The length of the visit can be the criterion for code selection only when counseling or coordination of care accounts for ≥ 50% of the time spent with a patient. In an SMA, the service delivered by a provider is medical E&M, not counseling or coordination of care.
Medicare Reimbursement for Group MNT and Group DSME/T
When all coverage criteria are met, Medicare allows for reimbursement of the E&M service and group MNT or group DSME/T that each beneficiary receives in the SMA on the same day. The group MNT or group DSME/T must be billed under a national provider identification (NPI) number that is different from the NPI number of the E&M provider (i.e., MNT or DSME/T must be rendered by a different provider).
Table 2 provides guidelines and tips for Medicare coding and coverage of SMAs for people with diabetes. Table 3 summarizes the required Healthcare Common Procedure Coding System (HCPCS) and CPT codes required for Medicare billing. Table 4 summarizes Medicare's key coverage criteria for these two benefits, and Table 5 offers an example of billing for MNT.
Payer and Medicaid Reimbursement for SMAs, Group DSME/T, and Group MNT
As with many services, billing for SMAs, group DSME/T, and group MNT requires that the billing/coding staff do preliminary work with private payers and state Medicaid plans to find out whether these services are payable benefits, and, if so, to learn their specific coverage guidelines. Many payers adhere to Medicare's coverage policies, but others do not. If these services are covered, each payer (including each state's Medicaid plan) will have its own coverage regulations, including the appropriate billing codes, utilization limits, and patient and provider eligibility requirements.
A common misconception is that DSME/T provided in an SMA cannot be billed for at all if the program is not accredited. Following is an example of DSME/T billing by an unaccredited program. Assume an SMA includes as participants two Medicare beneficiaries plus six patients with private health care plans that do not require accreditation. DSME/T claims cannot be sent to Medicare for the two beneficiaries. These beneficiaries are to be given an advanced beneficiary notice (ABN) form before the SMA starts. The notice should explain that the DSME/T furnished in the SMA is a covered benefit, but that the program does not meet Medicare requirements, and thus it cannot be billed, and Medicare will not pay for it. On the ABN, the beneficiary can either agree to receive the DSME/T and be financially responsible for the full fee or decline the service. Claims for the six patients with private health care plans that do not require program accreditation can be sent to these plans, adhering to each plan's coverage guidelines for DSME/T. If the private payers do not accept the G0109 code (for group DSME/T), or the 97804 code (for group MNT), other codes may be applicable, such as education and training by nonphysician practitioners for patient self-management using a standardized curriculum (CPT codes 98961 and 98962).8,10
Resources for SMAs
The following Web sites offer free, downloadable how-to guides that can help diabetes professionals implement SMAs:
American Association of Clinical Endocrinologists: www.aace.org
American Academy of Family Physicians: www.aafp.org
VA Shared Medical Appointments for Patients with Diabetes: Maximizing Patient and Provider Expertise to Strengthen Care Management: Guide and Resources for Starting and Sustaining Successful SMAs: www.queri.research.va.gov/tools/diabetes/shared-med-appt.pdf
Advantages of diabetes-focused SMAs provide a triple win for clinics that utilize them:
Providers win through more efficient use of their limited time and resources, thus improving their financial bottom line.
Patients win through increased peer support and education, expanded time with their provider, and improved outcomes in terms of knowledge, behavior, clinical parameters, health status, cost-savings, and satisfaction.
Payers win through reduced costs associated with patients whose outcomes improve.
SMAs are not suitable for every provider or every patient, but they offer a potential option for follow-up medical management visits. A careful review must be made of the practice entity's patient mix, along with an analysis of the availability of resources and staff necessary to furnish SMAs effectively and safely. If this care delivery model is selected, there are many benefits to be realized. The acronym MORE can be used to succinctly highlight the benefits of SMAs for diabetes care. Providers, patients, and payers get MORE (Maximization of Outcomes, Revenue, and Empowerment of patients).