American Physical Therapy Association
Recent Coding Issues and One-on-One and Group Patient Scenarios
CMS has established a correct coding initiative edit that prohibits billing for group therapy along with certain therapeutic procedure CPT codes (97110, 97112, 97116, 97140, 97530, 97532, 97533) in the same session unless a –59 modifier is used in certain settings. To be reimbursed for both services, the providers documentation must support that the group therapy and the therapeutic procedure were performed during separate time intervals.
Lastly, APTA does not interpret Transmittal 1753 as prohibiting payment for a supervised (unattended) modality and a one-on-one service being delivered to two patients in the same time interval. For example, Patient A is receiving unattended electrical stimulation at the same time as patient B is receiving therapeutic exercise…
These are intended to be examples of proper coding for billing purposes.
They are not intended to establish a standard for clinical practice.
Physical therapist sees patient A at 9:00 am for 30 minutes of therapeutic exercise. At 9:15 am patient B arrives and begins his visit with 15 minutes on the treadmill focusing on muscular recruitment and posture, assisted by a physical therapist assistant. At 9:30 the physical therapist sets up patient A to begin electrical stimulation (unattended). Following patient A's set up, the physical therapist begins working with patient B on gait training while patient A continues to receive electrical stimulation (unattended). At 9:55, the physical therapist briefly assesses Patient A following completion of the electrical stimulation and then patient A leaves the clinic. The physical therapist then completes Patient B's gait training and patient B leaves the clinic at 10:10 am.
- Patient A: 97110 (therapeutic exercise) 2 units
- 97014 (electrical stimulation, unattended)
- Patient B: 97116 (gait training) 2 units
- 97112 (neuromuscular reeducation) 1 unit
The physical therapist is one on one with Patient A from 9:00-9:30, and therefore two units of therapeutic exercise (97110) would be billed. Patient A's electrical stimulation (97014) is also billable as it is a supervised modality.
The time that Patient B spends with the physical therapist assistant from 9:15-9:30 is billable as one unit of neuromuscular reeducation (97112) as the physical therapist assistant is providing skilled therapy services under the supervision of the physical therapist. In addition, the time spent with the physical therapist from 9:30-10:10 is also billable as 2 more units of gait training (97116) because the physical therapist is one on one with Patient B. It is appropriate to bill 2 units of gait training ...