by David Klein, CPC CPMA CHC
Oct 31st, 2017 - Reviewed/Updated Feb 5th
Recent events regarding delegation of services to ancillary personnel have given rise to concerns regarding the delivery of outpatient physical medicine by Chiropractors, specifically regarding the appropriate use of one-on-one codes as opposed to group therapy code CPT 97150 - Therapeutic procedure(s), group (2 or more individuals). This advisory provides guidance on how to properly use one-on-one and group therapy codes, both independently and together.
Certain codes, CPT 97110-97139, require direct one-on-one patient contact by the Physician. When direct one-on-one patient contact is provided, the Physician bills for individual therapy and counts the total minutes of service to each patient in order to determine how many units of service to bill each patient for the timed codes (e.g. each 15 minutes). These direct one-on-one minutes may occur continuously (15 minutes straight), or in different episodes (for example, 8 minutes now, 7 minutes later). According to Medicare (CMS), “each direct one-on-one episode, however, should be of a sufficient length of time to provide the appropriate skilled treatment in accordance with each patient's plan of care.” Both the AMA and Medicare state that a minimum of at least 8 minutes must be met/documented for a single unit to be billed.
There are times when the Physician is not one-on-one and must deliver skilled services to more than one patient in a given time period. In such instances, the Physician is no longer one-on-one and is instead providing services in a group setting. If this situation arises, the Physician should report CPT 97150 (group therapy) as opposed to the one-on-one CPT code(s).
Group therapy consists of simultaneous treatment to two or more patients who may or may not be doing the same activities. If the Physician 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. Group therapeutic procedures only include CPT codes 97110-97139. For example, group therapy does not include CPT 97035 (ultrasound). Group therapy procedures involve constant attendance of the physician, but by definition do not require one-on-one patient contact by the same physician or other qualified health care professional. Only one unit of group therapy may be billed per patient per date of service.
Below are two examples based on the CMS advisory “11 Part B Billing Scenarios for PTs and OTs”, one involving “one-on-one” service and the other involving “group therapy”:
In a 45-minute period, a physician works with 3 patients - A, B, and C - providing therapeutic exercises to each patient with direct one-on-one contact in the following sequence: Patient A receives 8 minutes, patient B receives 8 minutes and patient C receives 8 minutes. After this initial 24-minute period, the Physician returns to work with patient A for 10 more minutes (18 minutes total), then patient B for 5 more minutes (13 minutes total), and finally patient C for 6 additional minutes (14 minutes total). During the times the patients are not receiving direct one-on-one contact with the Physician, they are each exercising independently. The Physician appropriately bills each patient one 15 minute unit of therapeutic exercise (97110) corresponding to the time of the skilled intervention with each patient.
In a 25-minute period, a Physician works with two patients, A and B, and divides his/her time between two patients. The Physician moves back and forth between the two patients, spending a minute or two at a time, and provides occasional assistance and modifications to patient A’s exercise program and offers verbal cues for patient B’s gait training and balance activities in the parallel bars. The Physician does not track continuous or notable, identifiable episodes of direct one-on-one contact with either patient and would bill each patient one unit of group therapy (97150) corresponding to the time of the skilled intervention with each patient.
Can Group and Individual CPT Codes be Billed on Same Day?
Billing for both individual (one-on-one) and group services provided to the same patient in the same day is allowed according to Medicare and Current Procedural Terminology. However, the CPT and CMS rules for one-on-one and group therapy must both be met. Of particular importance is the fact that the group therapy session must be clearly distinct or independent from other services and billed using a -59 modifier. These rules require the group therapy and the one-on-one therapy to occur in different sessions, timeframes, or separate encounters that are distinct or independent from each other when billed on the same day. The Physician would use the -59 modifier to bill for both group therapy and individual therapy CPT codes to distinguish that the two coded services represent different sessions or separate encounters on the same day. Without the -59 modifier, payment would be made only for the lower-priced group therapy CPT Code, in accordance with CPT/CCI rules.
One-on-One and Group Example:
In a 45-minute period, a physician works with 2 patients – A and B. In the first 15 minute period the Physician provides therapeutic exercises to patient A with direct one-on-one contact for 15 minutes. After this initial 15-minute period, patient B arrives. The Physician then works with the two patients, A and B, and divides his/her time between the two them. The Physician moves back and forth between the two patients, spending a minute or two at a time, and provides occasional assistance and modifications to patient A’s exercise program and offers verbal cues for patient B’s core activities using Therabands. When the patients are not receiving direct one-on-one contact with the Physician, they are each exercising independently. The Physician works with patient A for 15 minutes and patient B for 16 minutes during the Group session. At the end of the Group session, patient A leaves. The Physician then provides therapeutic exercises to patient B with direct one-on-one contact for an additional 18 minutes. The Physician appropriately bills each patient one Group Therapy code (97150) and 1 unit of therapeutic exercise (97110) corresponding to the time of the skilled one-on-one intervention with each patient. Because therapeutic exercise (97110) is clearly distinct and performed independent from other group services, the -59 modifier would be appended to CPT 97110.
Billing - CPT Codes: Not Permitted
CMS provides some notable scenarios where Physicians should not bill in the same 15-minute (or other) time period, to the same, or to different patients.
- 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 (1) and (2) above -- (CPT codes 97032- 97542). For example: any CPT code for a therapeutic procedure (e.g. 97116-gait training) with any attended modality CPT code (e.g. 97035-ultrasound);
- 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);
David Klein, CPC, CPMA, CHC is the co-founder of PayDC www.paydc.com, a web-based fully certified EHR system that focuses on compliance and reimbursement. He is a certified professional coder and auditor through the American Academy of Professional Coders (AAPC), and is certified in healthcare compliance through the Health Care Compliance Board (HCCB). He is the Founder and President of DK Coding & Compliance, Inc. a health care consulting firm that focuses on audit defense, education, compliance and reimbursement issues. He can be reached at email@example.com
The following references are used throughout this advisory:
- CMS Advisory “11 Part B Billing Scenarios for PTs and OTs”
- Skilled therapy: Benefits Policy Manual, 100-02, Chapter 15, Sections 220 and 230
- CPT Definitions: CPT 2017, American Medical Association Press
- AMA CPT Assistant August 2006 page 11e, “Physical Medicine and Rehabilitation, 97110-97139, 97150 (Q&A)”
- Counting of timed codes: Claims Processing Manual, 100-04, Chapter 5, Section 20.3, and Program Memorandum AB-01-68 (May 1, 2001)