"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Tuesday, September 23, 2008

Physical Therapy Group Code is not a 'Red Flag'

Physical therapists can get in trouble when they don't bill the PT group code.

I've posted on this before.

I've indicated that physical therapists that do not use the group code (CPT 97150) may be billing one-on-one codes for treatment that probably meets the definition of group physical therapy.

That is called 'upcoding'.

The group code accurately reflects clinical behavior in a typical physical therapy clinic. That is, occasionally, you get busy and you have to supervise more than one patient at a time.

Physical therapists often 'dovetail' their patients - treat on a half-hour schedule but see each individual patient for, perhaps, one hour.

This means that, on average, the patient receives 2 units of 'one-on-one' constant attendance procedures. The Medicare website provides examples of 'constant attendance' procedures as follows:
"In the same 15-minute (or other) time period, a therapist cannot bill any of the following pairs of CPT codes for outpatient therapy services provided to the same, or to different patients. Examples include:
  1. Any two CPT codes for "therapeutic procedures" requiring direct one-on-one patient contact (CPT codes 97110-97542);
  2. Any two CPT codes for modalities requiring "constant attendance" and direct one-on-one patient contact (CPT codes 97032 - 97039);
  3. Any two CPT codes requiring either constant attendance or direct one-on-one patient contact - as described in (a) and (b) above -- (CPT codes 97032- 97542). For example: any CPT code for a therapeutic procedure (eg. 97116-gait training) with any attended modality CPT code (eg. 97035-ultrasound);
  4. Any CPT code for therapeutic procedures requiring direct one-on-one patient contact (CPT codes 97110 - 97542) with the group therapy CPT code (97150) requiring constant attendance. For example: group therapy (97150) with neuromuscular reeducation (97112);
  5. Any CPT code for modalities requiring constant attendance (CPT codes 97032 - 97039) with the group therapy CPT code (97150). For example: group therapy (97150) with ultrasound (97035);
  6. Any untimed evaluation or reevaluation code (CPT codes 97001-97004) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032 - 97039), therapeutic procedures (CPT codes 97110-97542) and group therapy (CPT code 97150)"
The therapist can also bill the physical therapy group code (CPT 97150) if their clinical behavior meets this definition:
"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 group therapy, 97150 (untimed)."
The physical therapy clinic is question did not, apparently, use the group code at all. This description is a summary of their reported fraud...

"Federal authorities said therapists routinely provided services to multiple patients at the same time, but billed government programs as if the therapists were providing one-on-one care."
Learn to use the group code.

To learn more about physical therapy Medicare compliance get free downloads at BulletproofPT.com .

8 comments:

  1. Would this qualify as using a group charge correctly.

    2 patients in a 30 minute slot.
    Pt 1- Ther ex 1 unit, group 1 unit
    Pt 2- Ther ex 1 unit, group 1 unit

    Donny

    ReplyDelete
  2. Donny,

    Best is to read the Medicare Group therapy Billing Scenarios at this site:
    http://www.cms.gov/TherapyServices/02_billing_scenarios.asp

    Good luck,

    Tim

    ReplyDelete
  3. Just treat one-on-one, drop the techs, and your patients will appreciate it and you'll be fine financially as well.

    ReplyDelete
  4. Guy,

    What do you think about those who say that physical therapists are fully qualified to delegate to any properly trained, but unlicensed, person procedures that do not require the one-on-one presence of the therapist?

    Will patients pay for this type of treatment?

    In a system where the patient is the judge of value, can physical therapists set up care processes where some of the care is delivered by unlicensed personnel and still attract patients?

    ReplyDelete
  5. do tricare patients have to be group or can they be seen without the 97150 code

    ReplyDelete
  6. Good information, thanks for sharing detailed stuff......medical coding and billing online

    ReplyDelete
  7. I have been impressed with your message. Great view! your content was very pleasant and interesting to readers. Thank you very much for posting this.Keep up with good work.Physical Therapy Software

    ReplyDelete
  8. Hello,

    The way you explained this article is superb. All the information are unique and good for the us. You can read more about electronic statements on the Medical Billing Collection page on my website.

    ReplyDelete

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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

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