Your First Step

Before launching your SMA program, you must confirm with your billing and compliance colleagues that the codes you plan to use are approved within your clinic or health system, and that your note templates meet established documentation guidelines. It is best practice to have your billing and compliance team communicate directly with insurers to align on expectations before you begin.

For reference, the American College of Physicians recommends that "physicians inform each insurer in advance of their intent to begin furnishing group visits and how they plan to bill for them, thus giving the carrier an opportunity to communicate any concerns it may have or request an alternative billing arrangement." The American Academy of Family Physicians similarly advises that, "for compliance purposes, we recommend that you ask for [the payer's] instructions in writing and keep them on file as you would any other advice from a payer."

There Are No Dedicated SMA Billing Codes

The absence of dedicated SMA billing codes has created significant confusion over the years. However, best practices from the past 30 years provide a workable framework for seeking reimbursement for every patient at every SMA visit.

The widely accepted approach is to treat each individual patient check-in during an SMA as a standard 1-on-1 follow-up visit. To meet billing requirements for the most commonly used follow-up visit codes — 99212, 99213, and 99214 — you must ensure that:

• Every patient receives individualized care from the billing provider during the SMA, and

• That care is documented in the medical record in the same manner as a traditional 1-on-1 follow-up visit, consistent with Medical Decision Making criteria.

As the American College of Physicians has noted: "Because group visits are relatively unusual, no nationally accepted standard has yet emerged for billing them, and there is no special code for standard group visits. Acceptable billing thus varies both geographically and among different carriers. In cases where carriers have yet to adopt policies on group visit billing, the practice may be able to gain acceptance of its own proposed methodology — usually billing for each patient individually based on the services documented in the chart, just as though the patient had been seen separately."

This approach is also supported by publicly available resources from Kaiser Permanente and BlueCross BlueShield of North Carolina. Because SMA billing practices vary widely, it is imperative that you review your billing approach with your Billing Compliance team before proceeding.

Individualized Care Is Essential

Because standard E/M codes are used for SMA billing, individualized care within the group context is essential. Decisions regarding data interpretation and/or treatment plans should result from a direct, individualized conversation between the billing provider and each patient during the SMA. The outcome of that conversation forms the patient-specific plan documented in the visit note. While educational or experiential components of the SMA can be referenced in the note, best practice is to document patient-specific data interpretation and/or treatment decisions to ensure that the E/M code accurately reflects the individualized care provided.

“Medical Decision Making” Criteria For CPT Codes 99213, 99214, and 99215

Unlike 1-on-1 visits, which can be billed based on time, SMA visits can only be billed based on Medical Decision Making (MDM), as defined by the American Medical Association (see table below). These guidelines apply to all insurers, including Medicare and Medicaid, which routinely reimburse for SMA visits. Although there is no national policy for insurance reimbursement of SMA, many people point to the published guidance from Blue Cross North Carolina as precedent.

The MDM table below requires billing providers to achieve 2 out of 3 elements. As a general guide:

• 99213 is typically appropriate for SMA focused on (1) one stable chronic illness with (2) low risk of morbidity from additional diagnostic testing or treatment (e.g., behavior change as the primary intervention).

• 99214 is typically appropriate for SMA focused on (1) two or more stable chronic illnesses with (2) either a moderate amount or complexity of data to be reviewed and analyzed (e.g., independent interpretation of tests) or moderate risk of morbidity from additional diagnostic testing or treatment (e.g., prescription drug management).