Billing codes for Centering

Hi Amber, if it's helpful I've posted some info on codes in another thread focused more broadly on strategies to get enhanced reimbursement:

centeringconnects.org/thread/255/enhanced-reimbursement-centeringpregnancy

FYI


www.aafp.org/practice-management/payment/coding/group-visits.html#.WR-nDT3PMjU.mailto

No official payment or coding rules have been published by Medicare. However, the question of "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", was sent to the Centers for Medicare and Medicaid Services (CMS) with a request for an official response. The request 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?"



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.



Some private payers have instructed physicians to bill an office visit (99201-99215) based on the entire group visit. For compliance purposes, we recommend that you ask for these instructions in writing and keep them on file as you would any other advice from a payer.



Where each individual patient is provided a medically necessary, one-on-one encounter, in addition to the time in the group discussions, there should be no problem in billing for the visit based solely on the documented services provided in a direct one-on-one encounter.



If your group visits include the services of nutritionists or a behavioral health specialist, contact payers to determine if that portion of the group visit can be directly billed by the non-physician provider. This typically would include codes for medical nutrition therapy (97804) or health and behavior intervention (96153).



Other codes that may be applicable are the codes for education and training for patient self-management involving a standardized curriculum (98961-98962). Neither these codes nor medical nutrition or behavioral health therapy are billed by physicians. Physicians must use evaluation and management codes to report these services.



Code 99078 describes physician educational services in a group. Again, it is necessary to contact the payer to verify that coverage of this service is a payable benefit.



As with many services, coding for group visits requires that billing and coding staff do preliminary work with payers to identify desired coding applications.

Hello,
I am a graduate student doing a project.  (Which I would LOVE to talk someone into taking on the program).  The project entails "starting a program".  Including budget for employees, cpt codes, procedure codes, pretty much everything!  I was looking through the posts and found that it varies by state.  I am from Pennsylvania.  Any ideas as to who/where I can find information?

Thank you in advance,

Lisa Shallis
Graduate student (WHNP student)

Q:  We typically do not allow new patients in group visits and bill Level 3 established E&M code. Is this what you recommend? I know some states do have codes for group care but I understood at least previously that in Ohio individual codes are preferred.

A:  You are correct, the general rule around billing for group care is to bill the appropriate E and M code for the assessment or medical care part of the visit.
  Any additional billing codes are very much state specific.