Eli's Rehab Report

You planned your group therapy (97150) session perfectly to accommodate three patients with similar therapy goals. But when one patient suddenly requires one-on-one direct therapist contact, do not carve out her session and report it using the individual therapeutic exercise code (97110) while still reporting group therapy for the other two patients. You should report 97150 for group therapy no matter what.

"When we set up group therapy, the rehab physician usually recommends a few patients with similar goals who he thinks should be grouped together," says Thomas Whitmire, PT, a private-practice physical therapist in Salt Lake City.

"Unfortunately," Whitmire says, "you can never predict how they'll do in a group, and we've had occasions where two or three patients are moving along great with the group's direction and one patient will stand out as obviously needing one-on-one attention." Whitmire offers the following example:

The physical therapist (PT) meets with a patient rehabilitating from knee surgery. They get into the pool, where the PT teaches the patient basic aquatic therapy exercises for 30 minutes. The PT reports two units of 97113 (Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises). Later that day, the PT meets with another new patient in the pool. He teaches the patient (who is rehabilitating from ankle surgery) aquatic therapy procedures for 25 minutes and reports two units of 97113.

One week later, the therapist asks both patients to return together, where he leads group aquatic therapy exercises. Although the knee-surgery patient performs her exercises without any problems, the ankle-surgery patient struggles to remain standing in the water, and the PT works almost exclusively with her to ensure that she maintains her balance.

Therapists receive conflicting advice on this type of scenario, Whitmire says. "Unfortunately, some billing consultants incorrectly advise therapists to report CPT 97150 (Therapeutic procedure[s], group [2 or more individuals]) with modifier -52 (Reduced services) or -53 (Discontinued procedure), followed by 97113 for the needy patient, and then to report just the group therapy code for the other patient." One of the many problems with this scenario, Whitmire says, "is that the second patient is no longer in a group if you report the individual code for the first patient."

No matter how you disperse your therapy services throughout the group, you should report only 97150 for each patient, says William E. Tierney, CPA, a healthcare consultant in Strathmere, N.J.

"You qualify as a 'group'once you have two or more patients," Tierney says. "Just like any group, the patients will have a variety of needs based on many factors, such as age, time already in therapy, multiple injuries and other problems. Concentrating more on one patient should mean that the rest of the group is going through their own therapy program just fine while the therapist continues to observe them."

From a clinical standpoint, the therapist may choose to continue that patient's therapy using only one-on-one modalities, Tierney says, "Whether the patient is part of the group is the therapist's judgment call, but too much therapist interaction with one patient may suggest that this patient should not be in the group at this time."

Section 15032 of the Medicare Carriers Manual advises carriers to reimburse outpatient PT or occupational therapy (OT) "provided simultaneously to two or more individuals by a practitioner as group therapy services. The individuals can be, but need not be performing the same activity. The physician or therapist involved in group therapy services must be in constant attendance, but one-on-one patient contact is not required."

Suppose the therapist does not provide simultaneous services, but instead works one-on-one with Patient A while Patient B stands by. The PT then turns and works one-on-one with Patient B while Patient Aexercises on her own. In this case, you can report individual therapy codes, according to "FAQs on Outpatient Therapy Billing for Group and One-on-One Therapy," which CMS published in January 2003. This does not constitute group therapy, even though both patients are in the same room.

Suppose your OT performs arm strengthening exercises with a motor-vehicle injury patient in the morning. Later that day, the OT works with the same patient and three others on activities of daily living (ADL) training, where they practice navigating their wheelchairs through various environments. The National Correct Coding Initiative (NCCI) bundles therapeutic exercises (97110) into the group therapy code 97150, but you can separate the two codes by appending modifier -59 (Distinct procedural service).

"FAQs on Outpatient Therapy Billing for Group and One-on-One Therapy" states that you can report both individual and group codes for the same patient on the same date but that the "group therapy session must be clearly distinct or independent from the other services and billed using a -59 modifier."

Because the therapist in the example provided the group and individual therapy during separate encounters, he or she should report 97150 and 97110-59.

Medicare allows private-practice therapists to report 97150 only once per patient per day, but what if the PT and OT both perform group therapy with the same patient, but during different times of the day?

"In private practice, PTs and OTs each have their own group provider number, so they should be able to report 97150 using their own numbers because they represent separate and distinct disciplines," Tierney says.