Group Therapy versus Individual Therapy.
We frequently receive questions when clients have trouble determining whether to bill for group therapy (97150) or individual therapy, such as 97110, 97530, etc as defined by the timed CPT codes for therapeutic procedures requiring direct one-on-one patient contact, when treating two or more patients during the same time period.
Whenever direct one-on-one patient contact is provided the therapist 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 for each patient under the timed code principles. These direct one-on-one minutes may occur continuously (15 minutes straight), or in “notable episodes” (10 minutes now, 5 minutes later). 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. Also, the manner of practice should clearly distinguish it from care provided simultaneously to two or more patients.
To somewhat simplify the decision “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 (un-timed). If however the therapist provides sufficient “individual time” to each patient, then the billing falls legitimately to the individual time coded procedures.
One-on-One Example: In a 45-minute period, a therapist 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 therapist 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 therapist, they are each exercising independently. The therapist appropriately bills each patient one 15 minute unit of therapeutic exercise (97110) corresponding to the time of the skilled intervention with each patient.
Group Example: In a 15 minute period, a therapist works with two patients, A and B, and divides his/her time between two patients. The therapist 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 therapist does not actually provide any continuous or notable, identifiable episodes of direct one-on-one contact with either patient and the time devoted individually to each patient totals less than 8 minutes per patient. This would require the therapist to bill each patient one unit of group therapy (97150) corresponding to the time of the skilled intervention with each participant in the 15 minute therapy session.
Individual Therapy and Group Therapy on the same day:
Occasionally, the therapist may provide individual attention to one patient and then move on to service one or more patients in addition to the one he/she just attended.
Modifier -59 permits a distinct procedural service to be billed for the same patient on the same day by the same provider. These distinct services are identified as independent of other services provided that day by using the modifier -59. The following are examples of correct use.
Billing for both individual (one-on-one) and group services provided to the same patient in the
same day is allowed, provided the CMS and coding rules for one-on-one and group therapy are both met, and that the group therapy session be clearly distinct or independent from other services and billed using a -59 modifier.
The group therapy CPT code (97150) and the direct one-on-one 15-minute CPT code for therapeutic exercises (97110), are a mutually exclusive CCI code pair unless the “59” modifier is used. 97150 is the column one (primary component) code while 97110 is the column two (inclusive component) code unless we distinguish the performance to separate time allotments. This requires the group therapy and the one-on-one exercise therapy to occur in different sessions, separate encounters, or different timeframes occurring sequentially, not concurrently, that are distinct or independent from each other.
When this occurs, the therapist would bill for both group therapy and therapeutic exercises, appending the -59 modifier to the column two code, 97110. Without the -59 modifier, payment would be made only for the column one group therapy CPT Code, 97150 since the individual therapy (97110)code would be interpreted as the “type of procedure” employed during the group activity rather than as a sequential (before or after) and separate “individual” session.
Contrary to the “wisdom” of some consultants, un-timed, unattended “modalities” (97010- 97028/ G0283 etc.) being administered to other patients do NOT constitute inclusion into the “group therapy” concept since, by nature and definition these codes DO NOT require direct one-on-one provide contact . If, however, the modality falls to the “Constant Attendance” modalities, (97032-97036) then the concept would apply.
Additional clarification of “specific situations” should be directed to your MedCorp Compliance Consultant for individual determinations and direction on the proper billing protocols. The 8 minute, timed procedure rules may apply and combination billing and documentation may be desirable for maximum reimbursements.
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