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Medicare Billing

The following is a summary provided by S3 Balance's legal counsel.

Group Therapy (CPT code 97150) is used to pay for outpatient PT/OT services 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 physical therapist(PT)/occupational therapist (OT) involved in Group Therapy services must be in constant attendance, but one-on-one patient contact is not required.

CPT code 97150 is an untimed, service-based code; therefore, class length does not matter. For example, if a PT/OT teaches an exercise class at a facility and the class is part of the Medicare-covered treatment for the patient, the PT/OT will bill a total of one unit of CPT 97150 per patient regardless of class length. If individual treatment is provided in addition to Group Therapy, the PT/OT may bill for the accompanying therapy provided.

In order for any exercise class to qualify as a covered service for Medicare payment, three requirements must be met:

(1) Participants are Medicare eligible; (2) The class is part of Medicare-covered plan of care for the patient; (3) The class is taught by a PT/OT or appropriately supervised PT/OT assistant.

Unless the Group Therapy treatment is already called for in an established plan of care by a PT/OT, a PT/OT will need to perform an initial evaluation of the patient and develop a plan of care. The plan of care requires the dated signature of the referring physician within 30 days of its creation, with recertification occurring every 90 days. See 42 CFR 424.24(c)(4)

Non-physician providers include PA-Cs, NPs and clinical nurse specialists.

The PT/OT must also update the patient file for every visit, for example noting whether the patient showed up for the session, what took place at that appointment, the time spent performing services and any observations that the PT/OT made while working with the patient. The PT/OT must also complete progress reports at least once every 10 treatment days or at least once during each 30 calendar days, whichever is less. See CMS Benefit Policy Manual System, Pub 100-002, Transmittal 88, Chapter 15, Section 230.1.

In a facility setting, the Group Therapy code may be applied more than once per day. However, the Centers for Medicare and Medicaid Services have advised that in the “occasional situation” where group therapy is billed more than once each day, CMS would require sufficient documentation to support its medical necessity and the clinical appropriateness of providing more than one daily session of Group Therapy.

Group Therapy must be supervised by a PT/OT or properly supervised and qualified PT assistant or OT assistant. Each PT/OT or assistant must meet specific Medicare personnel qualifications (See 42 CFR 484.4). The PT/OT cannot bill for the group session if it is supervised or taught by an aide or other staff member such as a nurse. The services of the PT/OT assistant are billed through the enrolled therapist or other therapy provider (See CMS Manual, supra; 42 CFR 484.4).

In addition, not only must the session be supervised, but the PT/OT or assistant must provide clinical expertise and judgment to the patients, such as offering feedback, providing further individualized instruction, implementing modifications and progressions of the exercise program for each patient, or measuring each patient's response to treatment. The services of a PT/OT or PT/OT assistant cannot be billed for supervising a patient who is independently performing a therapeutic exercise program. Without such active participation, the program will not be considered skilled PT/OT and will not be a covered service under Medicare.

The above information pertains to Medicare Part B patients. If the facility qualifies as a Skilled Nursing Facility or the PT/OT is provided under Plan A, different billing standards apply.

This information should not be construed as legal advice. The contents are intended for general informational purposes only, and readers are urged to consult their own legal counsel with regard to their specific circumstances, including the applicability and enforceability of state and local laws.