Document Chiropractic Group and Individual Therapy Differences
By Marty Kotlar, DC, CHCC, CBCS
Last month, we discussed coding and billing for therapeutic procedures and modalities in chiropractic practice, concentrating on services provided to individual patients (“Add Therapeutic Procedures and Modalities to a Chiropractic Practice,” pages 22-25). This month, we’ll explore proper billing and coding for group therapy, as well as additional individual therapy not covered last month.
Group vs. Individual Therapy Billing
Group therapy consists of simultaneous treatment for two or more patients who may (or may not) be doing the same activities. Group therapy procedures involve constant attendance of the physician or therapist, but by definition do not require one-on-one patient contact. If a doctor of chiropractic (DC) is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, it is appropriate to bill each patient one unit of group therapy using CPT® 97150 Therapeutic procedure(s), group (2 or more individuals).
Documentation to support 97150 must identify the specific treatment technique(s) used in the group, how the treatment technique will restore function, the frequency and duration of the particular group setting, the number of persons in the group, and the treatment goal in the individualized plan. The specific therapeutic procedure should not be reported in addition to this group therapy code.
For example: In a 25-minute period, a DC works with two patients, A and B. The DC moves back and forth between the two patients, spending a minute or two at a time with each, providing occasional assistance and modifications to patient A’s exercise program and offering verbal cues for patient B’s balance activities.
The proper coding for both patients is 97150. Documentation should identify the specific treatment technique(s) used in the group, how the treatment technique will restore function, the frequency and duration of the particular group setting, the number of persons in the group, and the treatment goal in the individualized plan.
Consider this one-on-one therapy example: A DC works with three patients, A, B, and C, providing and supervising therapeutic exercises to each patient with direct one-on-one contact in the following sequence: Patient A receives three minutes, patient B receives three minutes, and patient C receives three minutes. After this initial nine-minute period, the DC returns to work with patient A for five more minutes (eight minutes total), then patient B for 12 more minutes (15 minutes total), and finally patient C for 15 additional minutes (18 minutes total). When the patients are not receiving direct one-on-one contact with the DC, they are each exercising independently.
Each patient can be billed one unit of therapeutic exercise, CPT® 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
This scenario is different from group therapy because individual therapy requires direct, one-on-one patient contact for approximately 15 minutes with the provider to effect change by applying clinical skills and/or services attempting to improve function.
Billing for both individual (one-on-one) and group services provided to the same patient on the same day is allowed, if the rules for one-on-one and group therapy are both met.
For example: A patient is in a group setting with several other patients performing exercise therapy. The patient is then seen by the DC, who provides direct one-on-one contact for approximately 15 minutes, applying clinical skills and/or services to improve function.
The group therapy session must be clearly distinct or independent from other services. CPT® 97150 and the one-on-one codes (e.g., 97110, 97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities) are subject to National Correct Coding Initiative (NCCI) edits, which require group therapy and one-on-one therapy to occur in different sessions, timeframes, or separate encounters distinct or independent from each other when billed on the same day. Use modifier 59 Distinct procedural service when billing both group therapy and individual therapy CPT® codes to distinguish the two coded services as different sessions or separate encounters on the same day.
Reporting Therapeutic Activities and Self-care Training
Therapeutic activities (97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes) use functional activities (e.g., bending, lifting, carrying, reaching, catching, and overhead activities) to improve functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the professional skills of a provider and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active treatment plan and directed at a specific outcome.
An example of 97530 might be to increase flexibility of the quadratus lumborum muscles while activating and stretching the hamstring muscles to improve the patient’s capacity for walking and standing.
Self-care/home management training (97535 Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes) involves the use of ADL and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment, with direct one-on-one contact by the provider. The patient must have the capacity to learn from instructions. The documentation must relate the training to the patient’s expected functional goals, and the procedure must be part of an active treatment plan directed at a specific goal.
The overall goal should be to get the patient to return to the highest level of function realistically attainable and within the context of the presenting problem. The plan of treatment should address specific therapeutic goals for which modalities and procedures are outlined in terms of type, frequency, and duration. There must be an expectation the condition will improve significantly in a reasonable and generally predictable time period, based on the assessment of the patient’s rehabilitation potential.
Note: Therapeutic procedures and modalities are not covered by insurance when the documentation indicates the patient has attained the therapy goals or has reached the point where no further significant practical improvement can be expected.
Source: Medicare Benefits Policy Manual, section 220 – Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance.”
Documenting for Success with Unlisted Modalities
Getting paid for unlisted procedures can be complicated; however, there are several things you can do to increase your chances of reimbursement.
To begin with, call the carrier and ask if the procedure you are about to perform is covered. If it is a non-covered service, make sure the patient is made aware of this. Give the name and telephone number of the person you spoke with at the insurance company to the patient, so he or she can ask the carrier for their policy on unlisted procedures and non-covered services.
Even if the carrier does not pay for the unlisted procedure, I recommend billing the carrier. This will help the carrier see that you are providing the service, and the explanation of benefits (EOB) will hopefully show a “patient responsibility” remark code. Sometimes patients want their carriers billed for unlisted and non-covered services so they know for sure they paid you properly. The patient responsibility EOB helps patients become educated on how their carrier processes claims and makes it easier for you to get paid directly.
Often the carrier will deny the unlisted procedure due to “lack of medical necessity.” If this is the case, get the carrier to define “medical necessity.” Request the definition by fax or email and review it. You may be able to send in a pre-authorization letter in the future. Also, ensure the carrier understands the anticipated cost of the care with and without the unlisted procedure. Insurance carriers are always looking to save money. You should tell them how much money you anticipate saving them by minimizing the risk of future, more expensive procedures.
If you have clinical trials and research conducted by recognized bodies of physicians for the unlisted procedure, make sure you include that information in your pre-authorization letter, as well. Describe the condition of the patient, how much they’re suffering, and the impact of the pain on the patient’s life. Include a lay-term description of the procedure in your letter so anybody who reads it can understand. Try to relate the procedure performed to an existing CPT® code as support for reimbursement. Explain how your procedure differs to show why you didn’t choose an existing code.
CPT® 97039 Unlisted modality (specify type and time if constant attendance) is a very common unlisted procedure code. Some of the more common procedures linked to 97039 are low-level laser therapy, mechanical massage, and dry hydrotherapy beds. Depending on the service you are providing, 97039 may require direct one-on-one contact for treatment and may be categorized as a constant attendance modality. If you are in-network, contact the carrier to find out their position on 97039 and check the fee schedule: it may be a covered service. Always adhere to the American Medical Association (AMA) official coding guidelines unless your contract with a carrier stipulates otherwise.
How to Report Time-based Therapy Codes
Remember the Medicare guidelines for reporting time-based therapy codes reviewed last month. Namely:
1 unit = 8-22 minutes
2 units = 23-37 minutes
3 units = 38-52 minutes
4 units = 53-67 minutes
If a service represented by a 15-minute timed code is performed in a single day for at least 15 minutes, bill at least one unit. If the service is performed for at least 30 minutes, bill at least two units, etc.
When more than one service represented by 15-minute timed codes is performed in a single day, the total number of minutes of service, as noted in the chart above, determines the number of timed units billed.
Per Medicare rules, when a 15-minute timed service is performed for seven minutes or less on the same day as another 15-minute timed service also performed for seven minutes or less, and the total time of the two is eight minutes or greater, bill one unit for the service performed for the most minutes. Apply the same logic when three or more different services are provided for seven minutes or less.
The time of each specific modality and therapeutic procedure provided to the patient should be documented in the subjective, objective, assessment, and plan (SOAP) notes.