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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.56 Physician Evaluation and Management (E/M) Services : 9.2.56.4 Group Clinical Visits

9.2.56.4
Texas Medicaid may reimburse physicians for group clinical visits (procedure code 99078) providing clinical services and educational counseling to a group of clients with the same condition.
To be considered for reimbursement, procedure code 99078 must be billed for the same date of service by the same provider as E/M procedure code 99211, 99212, 99213, 99214, or 99215.
Group clinical visits may be reimbursed for established patients only. The client’s plan of care must be determined and documented in the medical record by the physician before attending group clinical visits.
Participation of established patients in a group clinical visit is optional. Informed consent must be obtained from the client and maintained in the medical record before rendering group clinical visit services.
Clients who participate in group clinical visits and who have diseases covered under the Texas Medicaid Enhanced Care Program (congestive heart failure, chronic obstructive pulmonary disease, diabetes, coronary artery disease, and asthma) must receive a referral to the disease management program. Clinical providers are encouraged to coordinate care with the Texas Medicaid Enhanced Care Program for clients who are eligible for the disease management program and choose to participate in the program.
The physician leading the group clinical visit is responsible for the effectiveness and content of the information provided during the group clinical visit.
Nationally approved curriculum on asthma and diabetes, such as that available through the American Association of Diabetic Educators and Asthma Education and Prevention Programs approved by the CDC must be incorporated into the educational portion of group clinical visits.
Group clinical visits must last at least 1 hour, but no longer than 2 hours, with a minimum of 2 clients and a maximum of 20 and must include:
An informational and instructional presentation. In order to promote self-management of the chronic disease, the group visit must include a presentation instructing and informing the client about clinical issues including how to prevent exacerbation or complications, proper use of medications and other therapeutic techniques, and living with chronic illness.
An encounter with the physician. A short (approximately 5 to 15 minutes per client), one-on-one, private, face-to-face encounter with the physician is required. This visit consists of a physical examination; the gathering, monitoring, and reviewing of laboratory and diagnostic tests; and medical decision-making, including an individual treatment plan. Documentation in the client’s medical record must support the level of E/M as approved by CMS guidelines.
The documentation of the individual treatment plan retained in the client’s medical record must include data collected (physical exam and lab findings), educational services provided, patient participation, referrals to the HHSC disease management program, and the beginning and ending time of the visit.
Group visits for conditions of diabetes or asthma are limited to a maximum of four per year for any provider.
9.2.56.4.1
Group clinical visits are benefits of Texas Medicaid for the management of the condition of diabetes when submitted with one of the following diagnosis codes:
 
Diabetic education must explain the following:
9.2.56.4.2
Group clinical visits are benefits of Texas Medicaid for the management of the condition of asthma when submitted with one of the following diagnosis codes:
 
Asthma education must consist of the following:
9.2.56.4.3
Group clinical visits are benefits of Texas Medicaid for the management of the condition of pregnancy when submitted with procedure code 99078 and modifier TH, along with one of the following diagnosis codes:
 
Providers are encouraged to provide a comprehensive curriculum or use materials from the Centering Pregnancy Program that will be incorporated into the educational portion of the group clinical visit.
Comprehensive curriculums will allow clinical issues to be identified to promote a healthy pregnancy. The education material may include screenings and preparations, health maintenance, counseling, and birth plans:
Group clinical visits for the management of pregnancy are restricted to female clients who are 10 through 55 years of age and are limited to a maximum of 10 visits per 270 days for any provider.
To be considered for reimbursement, procedure code 99078 with modifier TH must be billed for the same date of service by the same provider as E/M procedure code 99211, 99212, 99213, 99214, or 99215 with modifier TH.

Texas Medicaid & Healthcare Partnership
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