SMV Billing Strategies in FQHCs Fasih Hameed, MD Associate Medical Director, Wellness & Integrative Medicine, Petaluma Health Center Assistant Professor of Family Medicine, UCSF –Santa Rosa Family Medicine Residency

Benefits of SMA/SMV/Groups Increased contact time with patients Increased educational time Social interaction for isolated pts Group Learning Strengthening community Increased Access to care Delivery of innovative care support for goal setting and lifestyle change The intangible

Billing for Groups Mental Health Professionals CPSP Varies among insurance carriers Generally can bill one person in each group 90853 covered and reimbursed, but no wrap for FQHC Psychiatrist can bill SMV-style CPSP Bill one person in each group, unless 8 minutes of face to face time “one-on-one” time, then can bill individuals

Billing for Groups MD/DO/NP/PA Group, “shared medical visit”, individual visit conducted in front of others HIPPA disclosure and waiver Confidentiality reviewed Face-to-Face time documented and billed Bill appropriate E&M ONLY for individual services

Billing for Groups: Medical Acupuncture A standard office visit is conducted and documented Appropriate HPI, PE, Assessment and Plan is documented Bill for office visit Acupuncture is considered a “Complementary Complementary Service” May need scope change MD/DO only (no NP/PA) Acup specific CPT codes can be used as well, but may have to pay back depending on your system In California, it is a covered benefit for PHP/mediCal

AAFP guidance

AAFP guidance “…group visits are a proven, effective method for enhancing patient’s self-care...and improving outcomes.”

AAFP guidance “...individual evaluation could take place either separately or within the group process…” “…should code for the services provided using applicable, existing evaluation and management codes found in [CPT].”

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 (ie 99213) to a patient that is observed by other patients.”

From Blue Cross/Shield NC https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/group_visit_shared_medical_appointment_guidelines.pdf