11 Part B Billing Scenarios For Pts And Ots Centers

Summary

11 Part B Billing Scenarios for PTs and OTs
The following billing scenarios formerly appeared on the Frequently Asked Questions (FAQ)
website and on the Therapy Medlearn website as "11 FAQs" - posted 9/13/02 Open Door on
Group Therapy

CMS Assumptions
The following CMS assumptions were used in constructing the following billing scenarios
regarding Part B therapy services. These represent requirements that are necessary pre-conditions
to the information that follows and are part of the service delivery framework that CMS assumes
is in place when Part B therapy services are delivered:
Physical and Occupational Therapists (PTs and OTs) and their therapy assistants -
physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) meet
Medicare personnel qualifications

All therapy provided consists of skilled and medically necessary services and is
appropriate to each patient's plan of care

Therapists can enroll in Medicare as providers of PT or OT services, but therapy
assistants cannot. The services of the therapy assistant are billed through the enrolled
therapist, or other therapy provider

The therapist reports the time the therapy assistant provides care, whether it is one-on-one
care or delivered via the untimed codes, such as supervised modalities or group therapy

All Medicare rules are met with respect to supervision requirements for therapy assistants
in their respective settings. For example: (1) direct ("in the office suite") supervision in
private practice PT or OT therapy settings and (2) general supervision in the following
settings: Outpatient Prospective Payment System, Skilled Nursing Facility,
Comprehensive Outpatient Rehabilitation Facility, Rehab Agency and the Home Health
Agency

Each therapist's supervision of therapy assistant(s) is in compliance with all State laws
and regulations and with local medical review policies

References
The following references are used throughout the billing scenarios that follow:
1. Definitions of qualified therapy personnel: 42 C.F.R. 485.705, 484.4
2. Reasonable and necessary: Program Integrity Manual Chapter 13, Section 5.1
3. Skilled therapy: Benefits Policy Manual, 100-02, Chapter 15, Sections 220 and 230
4. CPT Definitions: CPT 2004, American Medical Association Press
5. Counting of timed codes: Claims Processing Manual, 100-04, Chapter 5, Section 20.3,
and Program Memorandum AB-01-68 (May 1, 2001)
6. SNF Therapy: Federal Register, 66 Fed. Reg. 39567 (July 31, 2002)
7. Correct Coding Initiative websites:
o Physician Fee Schedule
o Hospital Outpatient PPS
8. User's Manual for the Minimum Data Set (MDS) Version 2.0, Revised December 2008,
Revised Long Term Care Resident Assessment Instrument:
Reviewed 9/2009
1. Billing - CPT Codes: Not Permitted
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:
a. Any two CPT codes for "therapeutic procedures" requiring direct one-on-one patient
contact (CPT codes 97110-97542);
b. Any two CPT codes for modalities requiring "constant attendance" and direct one-on-one
patient contact (CPT codes 97032 - 97039);
c. 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);
d. 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);
e. 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);
f. 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)
See reference numbers 4. and 5. above

2. Billing - CPT Codes: Permitted
In the same 15-minute time period, one therapist may bill for more than one therapy service
occurring in the same 15-minute time period where "supervised modalities" are defined by CPT
as untimed and unattended -- not requiring the presence of the therapist (CPT codes 97010 -
97028). One or more supervised modalities may be billed in the same 15-minute time period
with any other CPT code, timed or untimed, requiring constant attendance or direct one-on-one
patient contact. However, any actual time the therapist uses to attend one-on-one to a patient
receiving a supervised modality cannot be counted for any other service provided by the
therapist

See reference numbers 4. and 5. above

3. Group Therapy vs. Individual Therapy:
The following is provided to assist you in determining whether to bill for group therapy (97150)
or individual therapy (defined by the timed CPT codes for therapeutic procedures requiring
direct one-on-one patient contact), when treating two patients during the same time period

Reviewed 9/2009
When 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 each patient for the timed codes. These direct one-on-one minutes may occur
continuously (15 minutes straight), or in notable episodes (for example, 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

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)

a. 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

b. Group Example: In a 25-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
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

See reference numbers 4. and 5. above

4. Team Therapy:
Therapists, or therapy assistants, working together as a "team" to treat one or more patients
cannot each bill separately for the same or different service provided at the same time to the
same patient

CPT codes are used for billing the services of one therapist or therapy assistant. The therapist
cannot bill for his/her services and those of another therapist or a therapy assistant, when both
provide the same or different services, at the same time, to the same patient(s). Where a physical
and occupational therapist both provide services to one patient at the same time, only one
therapist can bill for the entire service or the PT and OT can divide the service units. For
example, a PT and an OT work together for 30 minutes with one patient on transfer activities

The PT and OT could each bill one unit of 97530. Alternatively, the 2 units of 97530 could be
Reviewed 9/2009
billed by either the PT or the OT, but not both. Similarly, if two therapy assistants provide
services to the same patient at the same time, only the service of one therapy assistant can be
billed by the supervising therapist or the service units can be split between the two therapy
assistants and billed by the supervising therapist(s)

See reference numbers 4. and 5. above

5. Counting Minutes of Service Units
Billing of six units over a 60-minute period by providing direct one-on-one treatments to six
patients for 10 minutes each:
If more than one timed CPT code is billed during a calendar day, then the total number of units
that can be billed is constrained by the total treatment time. Medicare's expectation (based on the
work values for these CPT codes) is that a therapist's direct one-on-one patient contact time will
average 15 minutes in length, for each unit. Therapy sessions should not be structured to
consistently provide less than an average of 15 minutes treatment for each timed unit. Routine
billing of the above-described practice (10-minute treatment sessions) results in an average
workload that exceeds the expected timeframes and would likely cause the contractor to question
whether the services were reasonable and necessary

In the case of group therapy, an untimed code, Medicare expects that skilled, medically
necessary services will be provided as appropriate to each patient's plan of care. Therefore, group
therapy sessions should be of sufficient length to address the needs of each of the patients in the
group

See reference number 5. above

6. Group and Individual CPT Codes Billed on Same Day:
Billing for both individual (one-on-one) and group services provided to the same patient in the
same day:
This is allowed, provided the CPT and CMS rules for one-on-one and group therapy are both
met. However, the group therapy session must 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 Codes for
therapeutic procedures (97110 - 97542) are subject to Medicare’s National Correct Coding
Initiative (NCCI). The NCCI edits 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 therapist 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 for the lower-priced group therapy CPT Code, in accordance with
CPT/CCI rules. The CCI edits are based upon interpretation of coding rules

Reviewed 9/2009
The National Correct Coding Initiative website contains a link to NCCI FAQs that may be
helpful. In addition to the group therapy edits, NCCI edits are applied to certain other pairs of
CPT codes used by physical and occupational therapists. The NCCI website contains a link to the
National Technical Information Service (NTIS) website for information on obtaining the NCCI
Edits Manual and now lists current NCCI edits

See reference number 7. above

7. Supervision:
The services of a therapist or therapy assistant cannot be billed for supervising a patient who is
independently performing a therapeutic exercise program

Medicare pays only for skilled, medically necessary services delivered by qualified individuals,
including therapists or appropriately supervised therapy assistants. Supervising patients who are
exercising independently is not a skilled service

See reference numbers 1. and 3. above

8. Qualified Personnel:
You cannot bill Medicare for the services of an aide that is supervised by the therapist or therapy
assistant

Medicare Part B does not pay for the services provided by aides regardless of the level of
supervision. Medicare pays only for skilled, medically necessary services delivered by qualified
individuals, including therapists and appropriately supervised therapy assistants

See reference numbers 1. and 3. above

9. Group Frequency:
In private practice settings for physical and occupational therapists and in physician offices
where therapy services are provided incident to the physician, Medicare expects the group
therapy code (97150) to be billed only once each day per patient. In the facility/institutional
therapy settings, the group therapy code could be applied more than once. However, the
occasional situation where group therapy is billed more than once each day would require
sufficient documentation to support its medical necessity and clinical appropriateness of
providing more than one separate session of group therapy

See reference number 4. above

10. Documentation:
Records need to be maintained in order to demonstrate that billing for individual therapy or
group therapy was proper:
Reviewed 9/2009
CMS provides guidance on the reporting of service units that includes documentation
instructions. A therapist or therapy assistant should record the total treatment time (or the actual
beginning and ending time of treatment) for services described by timed codes, untimed codes
and unattended (billed and unbilled) activities. The total number of timed 15-minute units
that can be billed by the therapist (whether performed by the therapist or therapy
assistant) for each patient is constrained by the total time of the skilled therapeutic one-on-
one intervention by the therapist or therapy assistant. For the untimed codes, including
"supervised" modalities, group therapy, and the evaluation codes, documenting the session time
can help to justify the appropriateness of the services provided

Alternatively, in cases where recording the total treatment time may not be sufficient to describe
the extent of the therapeutic procedures or where certain practice policies require it, the time
spent delivering each service described by either a timed or untimed CPT code could be
recorded. In these cases, the therapist could document (a) the total time or the beginning and
ending time for each session defined by a timed code and/or (b) the total time (or segments of
time) in which the patient is involved in services defined by untimed codes and unattended
codes

See reference number 5. above

11. SNF Part B Billing:
In a SNF, when a therapist is working simultaneously with two or more residents - at least one
each from Part A and Part B - providing the same or different activities, the regulations for each
payer source must be followed. Examples of possible billing scenarios follow:
A therapist treats one Part A resident and one Part B resident during the same 30-minute
session, providing different activities to each, and does not track identifiable one-on-one
episodes of direct care with either patient. The therapist would bill one unit of 97150
(group) for the Part B resident, and code the total time, 30 minutes, toward the MDS as
individual treatment time for the Part A resident

A therapist treats one Part A resident and one Part B resident during the same 30-minute
session, providing the same or similar activities to each, and not tracking identifiable one-
on-one episodes of care with either patient. The therapist would bill one unit of 97150
(group) for the Part B resident and code the total time, 30 minutes, toward the MDS as
group treatment time for the Part A resident

Note: Part A therapy is different from Part B:
In order to be considered group therapy under Part A, the SNF residents perform similar
activities whereas, under Part B, the therapeutic interventions can be similar or different;
and,
SNF therapy services are paid as part of the bundled PPS rate and not reimbursed under
the physician fee schedule as they are under Part B

See reference numbers 6. and 8. above

Reviewed 9/2009

In the case of group therapy, an untimed code, Medicare expects that skilled, medically necessary services will be provided as appropriate to each patient's plan of care. Therefore, group …

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Frequently Asked Questions

How many part b billing scenarios are there for pts?

As a result, the 11 Part B Billing Scenarios are specific to PTs and OTs. We will update this Web Page to reflect changes in policy (for example, CCI edits, new codes, new coverage determinations) that impact therapy billing and/or to provide clarification on billing policy for PTs, OTs and/or SLPs.

Can a physical therapist and occupational therapist bill for the same patient?

"Therapists billing under Medicare Part B (i.e, outpatient) cannot bill separately for different (or the same) services provided to the same patient at the same time. So, even if a PT and OT co-treat a patient with a low functional level in an outpatient setting for safety reasons, they cannot both bill for the entirety of their time.

Can i bill for group therapy under part b?

When billing for group therapy under Part B—unlike Part A—the patients in the group do not require the same or similar diagnoses and they do not need to be doing the same or similar activities. Also, there is no limit to the number of people in the group.

Can ptas and otas treat medicare part b patients in the home?

However, the more recent public health emergency (PHE) Medicare Physician Fee Schedule (MPFS) mandate explains that direct supervision can be done virtually (via telecommunications technology). Therefore, PTAs and OTAs can treat a Medicare Part B beneficiary in the home as long as a PT or OTA is available by phone, two-way video, or text.