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PT Coding Sometimes Requires a Group Hug

Brad Ericson, CPC, CPC-ORTHO
Once a patient is evaluated by a physical therapist (PT), reporting outpatient therapy can become sticky. The reason is twofold: PT modality coding is largely based on 15 minute units, and a patient might receive a mix and match of massage, gait training, and myofascial release in the same hour, The other reason is that therapists sometimes treat patients individually and in a group at the same time.

Mixed Patients Add Complexity

When do you charge for the modality separately and when do you charge group therapy? The AMA CPT® code 97150 Therapeutic procedures(s), group (2 or more individuals) can be reported for each member of a group. AMA guidelines for code 97150 say “Group therapy procedures involve constant attendance of the physician or therapist, but by definition require one-on-one patient contract by the physician or therapist.” The Centers for Medicare and Medicaid Services (CMS) also defines group therapy in publication 100-2, Chapter 15: 230, saying patients can be, but don’t need to be, performing the same activity. The physician or therapist involved in group therapy services must be in constant attendance, but one-on-one patient contact isn’t required.
Here is where the clarity ends. What happens if you have a group of Medicare patients coming in and out who are treated by the same modality during one unit of their time in the clinic by the same clinician but not at exactly the same time? And what happens if you have a bunch of patients in a therapy pool? Rarely are pool patients performing the same exercises in unison. Do you report 97150 or 97113 Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises?

The Solution is Mixed, Too

Guidance is found thanks to the American Physical Therapy Association (APTA), which is working with CMS to additionally clarify the situation. The key is code 97150 in different situations. In one, the PT treats two or more patients whose condition or therapy has a common, unifying element. The patients might all be post-low back surgery or attending pool therapy. The clinician may provide some instruction and remain in attendance for the session for which 97150 is billed.
In another situation, however, two or more patients may not have unifying elements and receive diverse therapies, but never at the same time. The PT is in constant attendance and the patients may perform exercises developed for individual diagnoses and plans of care. They are, however, in the clinic at the same time with the same therapist, prompting the use of 97150.

Mix and Match

You can assign one-on-one codes along with the 97150 for those units when the therapist provides individual care. For example, while there are a number of patients in the facility receiving therapy following knee surgery, one patient may require neuromuscular reeducation of movement while another may require 15 minutes of gait training. In addition to 97150, the first patient would receive two units of 97112 Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities and the other would have one unit of 97116 Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing) along with 97150.
The duration of the group session for the applied code should be sufficient to ensure that professional services are provided. Because code 97150 is not broken into timed units, it can be used with other interventions provided on the same day of services, although modifiers may be required.

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