Time Adds Up
When Billing Group and Individual Therapy
By Shannon Sullivan, CPC, CMBS;
William Pena, PT, DPT; and
Carl Petitto, OTR/L
Part 2 of Our Physical Therapy Series
In Coding Edge’s April article, “PT and OT: Extend Coding Know-how to Full Capacity,” we discussed what constitutes reasonable and necessary physical therapy (PT) and occupational therapy (OT) services according to Medicare guidelines. We also explained how to determine whether a service is skilled; and we elaborated on untimed codes, timed codes, and individual treatment. In this second installment of a three-part series on PT and OT, we’ll explain the coding differences in group therapy and individual therapy.
Group vs. Individual Therapy
Let’s say the provider treats two patients during the same time period. Before choosing between group therapy code 97150 Therapeutic procedures(s), group (2 or more individuals) and individual therapy code 97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes (examples include activities such as bending and/or pulling), there are guidelines to consider.
When providing direct one-on-one patient contact, the therapist should bill for individual therapy and count the total service minutes to determine how many units of service to bill each patient. These direct, one-on-one minutes may occur continuously (15 minutes straight), or in notable episodes (for example, 10 minutes now, five minutes later). Each direct one-on-one episode should be long enough to provide the appropriate skilled treatment in accordance with each patient’s care plan. The manner of practice should clearly distinguish the care from that provided simultaneously to two or more patients.
One-on-one example: In a 45-minute period, a therapist works with patients A, B, and C, providing therapeutic exercises to each patient with direct one-on-one contact in the following sequence: Patient A receives eight minutes, patient B receives eight minutes, and patient C receives eight minutes. After this initial 24-minute period, the therapist returns to work with patient A for 10 more minutes (18 minutes total), then patient B for five more minutes (13 minutes total), and finally patient C for six additional minutes (14 minutes total). During the times the patients are not receiving direct one-on-one contact with the therapist they are each exercising independently. The therapist appropriately bills each patient one 15-minute unit of therapeutic exercise (97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility), corresponding to the time of the skilled intervention with each patient.
Group therapy consists of simultaneous treatment to two or more patients who may (or may not) be doing the same activities. If the therapist 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 untimed group therapy (97150).
Group example: In a 25-minute period, a therapist works with patients A and B, spending a minute or two at a time with each patient, providing occasional assistance and modifications to patient A’s exercise program, and offering verbal cues for patient B’s gait training and balance activities on the parallel bars. The therapist does not track continuous or notable, identifiable episodes of direct one-on-one contact with either patient. In this case, the therapist would correctly bill each patient one unit of group therapy (97150).
Refer to Medicare Policy for Guidelines
The document guidelines in the Centers for Medicare & Medicaid Services (CMS) pub. 100-02, Medicare Benefit Policy Manual, chapter 15, sections 220 and 230 (“Group Therapy vs. Individual Therapy”), identify the minimal expectations of documentation by providers, suppliers, or beneficiaries submitting claims for payment of therapy services to the Medicare program. Medical review decisions are based on the information submitted in the medical record, so the medical record should be accurate and complete to ensure a fair payment decision.
Medical record information submitted should:
- paint a picture of the patient’s impairments and functional limitations requiring skilled intervention;
- describe the prior functional level to assist in establishing the patient’s potential and prognosis;
- describe the skilled nature of the therapy treatment provided;
- justify that the type, frequency, and duration of therapy is medically necessary for the individual patient’s condition;
- clearly document both Timed Code Treatment Minutes and Total Treatment Time to justify the units billed; and
- identify each specific skilled intervention/modality provided to justify coding.
For example, a physical therapist may document services provided by stating, “Patient was provided with ultrasound at 1 mhz, 1.8 w/cm2, 80 percent duty (10 min.) to area of R piriformis followed by light sustained stretch to piriformis (16 min.), concluding with patient education to SROM as part of HEP (11 min.). Patient was educated with visual, verbal, and written instruction. She demonstrated full competency and was without questions.” The above interventions also may be documented on an attached flow sheet that shows treatment provided and the duration of each. In the therapist’s note, he or she would document, “See attached treatment log.”
Non-covered indications for maintenance programs include the following:
- Non-individualized services
- Services considered routine or non-skilled (eg, supportive nursing services)
- Maintenance programs for patients without a complex condition that requires development of such a program by a skilled therapist
- Exercises or activities that could have been transitioned to an independent or caregiver assisted program (eg, consistently repetitive exercises/activities)
- Non-cooperation by patient or caregiver(s)
- Continuation of treatment solely for the purpose of staff training and education or development of a formal maintenance program after rehabilitative therapy completion.
In an upcoming issue of Coding Edge, we’ll complete this three-part series with a discussion on documentation guidelines and what constitutes as unauthorized personnel providing outpatient therapy services.
Shannon Sullivan, CPC, CMBS, holds a bachelor’s degree in business management and is managing owner of Atlantic Billing & Coding, LLC. She is president of the local coding chapter in her area, which she founded last year. You can reach her at firstname.lastname@example.org.
William Pena, PT, DPT, holds a doctorate in physical therapy and is an owner of a private practice, continuing patient treatment in a variety of settings. He is also an owner and manager of Atlantic Billing and Coding, LLC, and is a certified health care compliance consultant. William performs audits for private physical therapy practices. He can be reached at email@example.com.
Carl Petitto, OTR/L, holds a bachelor’s degree in occupational therapy, health and human services. Carl is an owner of a private practice, continuing patient treatment in a variety of settings. He is also an owner and manager of Atlantic Billing and Coding, LLC, and is a certified health care compliance consultant. He earned a commission in the U.S. Army Reserve as an occupational therapist.