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Providing Follow-up Care through Shared Medical Appointments (SMAs) is a Win-Win-Win Approach

May 25, 2010



by Greg Milliger, CPC, CPC-H, CPC-P, CEC, CEMC, CPC-I,

President, Unique Healthcare Consulting, Inc.


Shared Medical Appointments (SMAs) are visits when multiple patients meet with a provider (an MD, DO, NP, PA or CNS), and at times a behaviorist at the same encounter, for a follow-up visit related to a condition such as diabetes. An SMA requires that the provider make a medical decision and document this decision in each patient’s record. Education provided by the provider or staff is considered incidental to the encounter and is not claimed separately.

The total time involved in a SMA is usually 60–90 minutes depending on the number of patients in the group. The individual time a provider spends with a patient can vary greatly but is routinely no more than 5 minutes. SMAs are coded based upon the documentation in each patients record (CPT® 99212-99215).

Time cannot be used as the controlling factor for the patient encounter unless they are seen outside of the SMA on the same calendar date. Some payers may require HCPCS II modifier TT, indicating individualized services with multiple patients present, be appended to the E/M code claimed. Medicare does not recognize modifier TT. If an educator meets with the group of patients before or after the SMA, their Diabetes Self-Management Training (DSMT) or Medical Nutrition Therapy (MNT) services can be claimed as long as the National Provider Identifier (NPI) number used is different from the provider’s number who provided the E/M services.

Today, SMA’s are being conducted for:

  • Diabetes
  • Gastric Bypass & Banding Post-op Patients
  • Thyroid
  • Annual GYN Exams
  • Asthma
  • Panic Disorder
  • Medical Weight Loss
  • Women’s Health
  • Depression
  • Gynecology
  • Arthritis
  • Osteoporosis
  • Headache
  • Annual Physicals
  • Hypertension

It’s a Win-Win-Win Situation

The provider wins through more efficient use of their limited time.

Advantages for providers:
  • Patient retention;
  • Fewer ER visits and/or admissions;
  • Increased billable hours;
  • Increased patient satisfaction;
  • Guideline implementation/adherence by the patient;
  • Efficiency; and
  • Less isolation.

The patient winsthrough better outcomes in reducing A1c levels and they gain an expanded time with their provider.

Advantages for patients:
  • Reduced isolation;
  • Peer education;
  • Increased satisfaction;
  • Guideline implementation and adherence; and
  • Increased time with providers.

The payer wins through the reduced costs associated with a DM patient.

SMA Delivery System Design

  • The entire office staff works as a team;
  • There is a shared responsibility for the quality and reliability of the care delivered;
  • A common understanding of roles, responsibilities and hand-offs;
    • Evidence-based guidelines are used in daily practice.
    • Healthcare team members are trained on the guidelines.
    • Are able to provide outcome measurements;
    • Have a task list available to follow during each visit;
    • Follow established timeline;
  • A “game plan” has been discussed and all commit to accomplishing;
  • Have clear and concise responsibilities among staff; and
  • Patient visits are planned.
    • Have the patient list prepared prior to each SMA visit.

All patients and support personnel should sign a release approved by the provider’s Legal Department. In this release, items such as the below would be discussed:

  • The behaviorist’s introduction, role and the advantages;
  • How an SMA provides access to the busiest services, especially for new patients;
  • How time is dramatically decreased for follow-up patients and physicals;
  • Provide patients with enhanced condition-specific support and education; and
  • Cover in all promotional items.

Items to stress within the release:

  • Medical issues will be discussed in a group setting;
  • Do not identify other patients outside of group; and
  • Do not discuss patient’s health problems after group.

All patients and support personnel should sign the release before each session starts.

The Flow of a Typical Shared Medical Follow-up Appointment:

  • 9-12 patients register in a physician’s office;
  • Nurse starts vitals 10 minutes early;
  • Patients sit in a semicircle, with the Physician next to the Behaviorist;
  • Behaviorist’s introduction to patients;
  • Physician starts with patients needing to leave early;
  • Physician then addresses rest of patients individually;
  • Physician documents a chart note after each patient visit;
  • Private exams and simple procedures last approximately 10 minutes;
  • The goal is to end on time with charting finished; and
  • The Behaviorist stays with the patients until they leave and straightens area.
 During the visit:
  • Create a comfortable atmosphere for the patients;
  • Set  an agenda;
  • Allow the participants to do the talking;
  • Use flipcharts and colorful presentations; and
  • Present strong and clear closings.
After the visit — follow-up:
  • Debrief with staff.
    • Provide any improvement recommendations.
  • Plan the next SMA visit.
    • Define notification process.

Billable Hours

  • The typical face-to-face time slot for an individual DM patient follow-up is 15 to 20 minutes or 4 patients per hour which include time to document each patient’s note.
  • The typical face-to-face time slot for an SMA is 40 minutes.  The typical size of a SMA is 8 to 10 patients.  Add 20 minutes to the 40 minutes to include the time to document each patient’s note for a total of 60 minutes.

The net result is you have just increased your productivity by at least 100% while at the same time increasing your DM outcomes and increasing patient satisfaction with your services.

Items to Note
  • Bill as individual appointments;
  • Code according to level of care delivered & documented; and
  • Do not bill for counseling time.

Lessons Learned by Others

  • Do not ask your patient if they want to attend an SMA. Advise them you would like to schedule a follow-up visit where the patient sees the provider for a follow-up on their diabetes and together with other DM patients;
  • Do not allow patients to think an SMA visit is an extracurricular activity;
  • Do not offer food or schedule patients after hours;
  • Do not exceed 40 minutes of your time as a provider; and
  • Take vitals in a separate cubical or room.
Evidence of Positive Outcomes from SMA Participation
  • Results are lower A1c’s of -1.3 vs. -0.22;
  • Decreased admissions;
  • Increased satisfaction with diabetes care;
  • Quality;
  • Responsiveness;
  • Convenient and easy access; and
  • Increased self-efficacy.
(Sadur, CN, et al, Diabetes Care. 22(12): 2011-2017)
Keys to Success:
  • “All programs must be carefully designed, adequately supported, & properly run;”
    • Administrative support
    • Best possible champion
    • Meeting targeted census
    • Skilled & trained team
  • Quality marketing materials;
    • Promote program well.
  • Maximize behaviorist’s role;
    • Expand nurse/MA’s role.
    • Use well-designed Pt packet.
    • Engage administrative staff.
  • Train support staff;
  • Solve operational problems;
  • Finish on time;
  • Get documentation support.
Common Mistakes
  • Not consistently meeting census;
  • Not overbooking for “no-shows”;
  • Not securing required support;
  • Poor program design;
  • Not using established models;
  • Cheap, not best, personnel;
  • Lack of training;
  • Inadequate facilities;
  • MD not fully delegating to team;
  • Not finishing charting in session;
  • No documentation support;
  • MD not succinct & focused;
  • Not finishing on time; and
  • Behaviorist not pacing group.
In Summary
  • SMAs can increase access and reduce backlogs without increasing clinic time for patients with DM;
  • SMAs are best for the hopelessly backlogged physician;
  • SMAs can boost productivity and improve patient care;
  • SMAs must be done correctly:
    • SMAs are not a class;
    • Must be one on one interaction;
    • Must appropriately document.
  • SMAs are not for every physician or patient.