Group Medical Visits: Structure and Billing
Group medical visits (GMVs) are billable encounters where a healthcare provider sees multiple patients (typically 6-20) simultaneously for 60-120 minutes, combining individual medical management with group education and peer support, and can be billed using standard evaluation and management (E/M) codes for each patient seen. 1, 2
How Group Medical Visits Work
Basic Structure
- Group size: 6-20 patients with similar chronic conditions meet together for 60-120 minutes 2, 3
- Format: Combines individual one-on-one physical examinations with group discussion, education, and medical management 4, 5
- Provider team: Typically includes a physician or nurse practitioner (billable provider) plus nurses, pharmacists, or other support staff 1
- Setting: Requires a conference/meeting room for group education plus private areas for individual examinations 1
Clinical Components
GMVs incorporate three main curriculum elements 2:
- Didactic education (present in all GMVs): Medical topics including symptom management, medication optimization, and lifestyle education covering nutrition, exercise, stress management, and sleep 2
- Experiential activities (in 49% of GMVs): Hands-on learning, skill-building exercises, and integrative medicine modalities such as mindfulness, meditation, and yoga 2
- Socialization component (in 22% of GMVs): Peer support, shared experiences, and community building among participants 2, 6
Billing for Group Medical Visits
Primary Billing Codes
Bill standard E/M codes (99201-99215) for each individual patient based on the complexity of their care, NOT a single group code. 1 There is no specific CPT code for "group visits"—this is a major implementation challenge 3.
For each patient in the group visit, you bill:
- 99213-99215 for established patients (most common scenario) based on medical decision-making complexity and time spent on individual care 1
- 99202-99205 for new patients establishing care 7
- Document individual assessment, medication adjustments, and care planning for each patient separately 1, 8
Critical Billing Requirements
Documentation must support individual patient care 8:
- Record individual patient history updates, physical examination findings, and medication changes
- Document time spent on each patient's individual care (can include time during group education if addressing that patient's specific needs)
- When >50% of encounter time is counseling/coordination, time-based coding is appropriate 1
Additional Billable Services
Chronic care management codes can supplement GMV billing 1:
- 99490: 20 minutes/month of non-face-to-face chronic care management (care coordination, phone calls, between-visit management) 1, 8
- 99487: 60 minutes/month complex chronic care management for patients with multiple complex conditions 1, 8
- 99489: Each additional 30 minutes beyond the initial 60 minutes 1
Other separately billable services 1:
- Vaccine administration codes (90460-90461) plus vaccine product codes 1, 7
- Preventive counseling codes (99401-99404) if provided separately from E/M visit 1
- Screening and assessment codes (96127 for behavioral screening, 96110 for developmental screening) 1
State-Specific Considerations
Insurance Coverage Variations
- Medicare: Covers standard E/M codes for GMVs and chronic care management codes (99490,99487) 8
- Medicaid: Coverage varies significantly by state; many state Medicaid programs do not reimburse chronic care management codes or may have restrictions on GMV billing 1, 8
- Commercial insurance: Most cover E/M codes for GMVs, but reimbursement rates and policies vary by carrier 8, 3
Critical pitfall: Verify with each payer whether they reimburse for GMV encounters before implementing this model, as some may deny claims if they determine the visit was "group-based" rather than individual 3.
Telehealth Options
- Virtual GMVs are feasible: Can be conducted via telehealth with breakout rooms for individual examinations 1
- Telehealth billing: Use standard E/M codes with appropriate telehealth modifiers per your state's telehealth parity laws 1
- Particularly valuable for patients with transportation barriers, childcare limitations, or geographic distance from clinic 1
Implementation Recommendations
Patient Selection and Recruitment
- Best candidates: Patients with complex chronic conditions requiring intensive education and support (diabetes, heart failure, chronic pain, multiple chronic conditions) 1, 2, 5
- Recruitment method: Physician referrals are most common and effective 2
- Retention strategies: Address logistical barriers including scheduling conflicts, transportation, and childcare needs 3
Administrative Requirements
Secure adequate administrative support before launching GMVs 3:
- Dedicated space with both group meeting area and private examination rooms 1
- Staff time for scheduling, patient education about the GMV model, and coordination 3
- Clear communication with patients about what to expect and how billing will work 1
Payment Model Alternatives
Beyond traditional fee-for-service, consider 1:
- Episode-of-care payment: Single payment covering multiple services and providers for a defined care episode 1
- Patient management fee: Monthly per-patient payment covering all care coordination, education, and between-visit management 1
- Shared medical appointments within Patient-Centered Medical Home (PCMH) models: May receive enhanced reimbursement 1
Common Pitfalls and Solutions
Billing Challenges
Pitfall: Attempting to bill a single "group code" for all patients 3
Pitfall: Inadequate documentation of individual patient care 8
- Solution: Create templates that capture individual assessments, medication changes, and care plans for each patient 8
Pitfall: Assuming all payers reimburse GMVs equally 3