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:The therapist can also bill the physical therapy group code (CPT 97150) if their clinical behavior meets this definition:
- Any two CPT codes for "therapeutic procedures" requiring direct one-on-one patient contact (CPT codes 97110-97542);
- Any two CPT codes for modalities requiring "constant attendance" and direct one-on-one patient contact (CPT codes 97032 - 97039);
- 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);
- 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);
- 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);
- 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)"
"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.
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