Billing for group visits

Beginning April 1, 2009, as part of Priority Health's initiative to support primary care providers in becoming patient-centered medical homes, Priority Health will reimburse code 99078 (group visits) fee for service to the primary care provider (PCP) and add the code to the fee schedule on standard Priority Health contracts.

• Payment will be made for all members of fully funded HMO, POS and PPO plans, with the exception of members with health savings accounts (HSAs) with unmet deductibles.
• No modifier is necessary to bill these codes.
• These codes are not payable for members of self-funded or shared-funded plans.
• These codes are not payable for members of Medicare, Medicaid or MiChild plans.

Reimbursement rate
The reimbursement rates for these codes already exist in our standard fee schedules, based on your geographical region.
Call the Provider Help Line or your provider representative to request your region's fee schedule.

Rationale for reimbursing group visits
Group visits (shared medical appointments) can be satisfying to both the physician and the patient. They can offer an increase in the productivity and efficiency of the health care team and can provide patients with an alternate visit, offering a holistic and therapeutic approach designed to improve patient access to and quality of care through enhanced education and support.

The AAFP lists a number of factors that can contribute to the success of group visits (shared medical appointments):

• Instill hope in patients by allowing them to see examples of success in managing a health issue.
• Add universality by disconfirming the uniqueness felt by patients regarding their conditions and/or health issues.
• Impart information and allay patient anxiety.
• Encourage an unselfish regard for the welfare of others.
• Promote imitative behavior and allow for positive role modeling among patient peers.
• Offer interpersonal and cognitive learning within the group setting.
• Provide group cohesiveness where peers can offer support among themselves.

Group visits are most appropriate for:

• Patients needing routine follow-up care
• Stable, chronically ill patients requiring total mind/body care
• Patients who typically require more time with their physician
• Patients who come for frequent return visits
• Patients with extensive emotional, informational, or psychosocial needs
• The "worried well"

Example of 99078:

1. The PCP may include other members of the care team (RN, Behavioralist, diabetic educator, nutritionist, etc.) in the group setting.
2. The PCP provides services to a member in a group setting.
3. The PCP reports 99078 in addition to the evaluation and management (E&M) service.