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CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.
Physical, Occupational, and Speech Therapy
1. Will Medicare pay for physical therapy services referred and/or established by a doctor of dental surgery or dental medicine (specialty 19) or by a chiropractor (specialty 35)? (Last Reviewed: July 16, 2008)
2. If a patient completed his/her physical therapy six (6) months ago, then returns again for additional therapy due to an exacerbation of the same diagnosis, is it within guidelines to bill a re-evaluation? (Last Reviewed: May 29, 2008)
3. What are the proper billing procedures for group pool session lasting 1 hour; should we bill code 97113 x 2 units or code 97150 x 1 unit? (Last Reviewed: May 29, 2008)
4. How do you bill for physical therapy services when two different physicians have ordered physical therapy (for different reasons) at the same time for the same patient, and there are two separate care plans? (Last Reviewed: June 6, 2008)
1. Will Medicare pay for physical therapy services referred and/or established by a doctor of dental surgery or dental medicine (specialty 19) or by a chiropractor (specialty 35)? (Last Reviewed: July 16, 2008)
No. Per Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, §220(A), under "Physician," it states, “Chiropractors and doctors of dental surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care.”
2. If a patient completed his/her physical therapy six (6) months ago, then returns again for additional therapy due to an exacerbation of the same diagnosis, is it within guidelines to bill a re-evaluation? (Last Reviewed: May 29, 2008)
No, after this amount of time, the original plan of care would have expired and would no longer be valid to treat this patient. Since this would be considered a new episode, it would be medically necessary for the patient to be evaluated to develop the plan of care, including goals and the selection of interventions.
The Upstate Medicare Division (UMD) has a local coverage determination (LCD), Physical Medicine and Rehabilitation (#PM003E08, Database #L13566) which explains coverage of physical therapy services. Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §§60, 220, 220.2, 220.3, 230.1, and 230.4 define coverage for outpatient physical and occupational therapy. Pub. 100-03, Medicare National Coverage Determination Manual, Chapter 1, §§150.1, 240.3, 30.3, 240.7, 160.2, 150.5, 160.3, 150.8, 160.15, 160.12, 160.17, and 160.13 concern modalities and other specific coverage topics related to physical therapy.
As stated in the LCD, "Codes 97001 and 97003 (evaluations) are normally performed once per episode."
In Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §§60, 220A, you will find the definition of an episode, an evaluation, and re-evaluation.
The episode of outpatient therapy - For the purposes of therapy policy, an outpatient therapy episode is defined as the period of time, in calendar days, from the first day the patient is under the care of the clinician (e.g., for evaluation or treatment) for the current condition(s) being treated by one therapy discipline (PT, or OT, or SLP) until the last date of service for that plan of care for that discipline.
An evaluation is a separately payable comprehensive service provided by a clinician, as defined, that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted, e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the plan of care, including goals and the selection of interventions.
A re-evaluation provides additional objective information not included in other documentation. Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement or decline or change in the patient's condition or functional status that was not anticipated in the plan of care for that interval. Although some regulations and state practice acts require re-evaluation at specific intervals, for Medicare payment, re-evaluations must meet Medicare coverage guidelines. The decision to provide a re-evaluation shall be made by a clinician.
3. What are the proper billing procedures for group pool session lasting 1 hour; should we bill code 97113 x 2 units or code 97150 x 1 unit? (Last Reviewed: May 29, 2008)
The Upstate Medicare Division (UMD) has a local coverage determination (LCD), Physical Medicine and Rehabilitation (#PM003E09, Database #L13566), which provides clinical guidelines for the therapeutic procedure 97113 (Aquatic therapy/exercises), as well as 97150 (Group therapeutic procedure(s)).
Providers should refer to Pub. 100-02, Medicare Benefits Policy Manual, Chapter 15, §230, which clarifies CPT code 97150. In this section, it clearly indicates group therapy services should be reported any time outpatient physical therapy services and occupational therapy services are provided simultaneously to two or more individuals by one practitioner.
According to the CPT manual, code 97113 requires direct one-on-one contact between the therapist and the patient. Therefore, code 97113 is for an individual patient and should not be billed when group therapy is involved.
Code 97150 indicates group therapy, specifically two (2) or more individuals. This is not a timed code. It may be billed only once per date of service. Group therapy sessions should be of sufficient length to address the needs of each of the individuals in the group. This service should be billed separately for each person in the group. The physician or therapist involved in group therapy services must be in constant attendance, but one-on-one patient contact is not required.
Therefore, only code 97150 (group therapy), with a quantity of one (1), can be billed for each individual attending a group pool session lasting an hour.
4. How do you bill for physical therapy services when two different physicians have ordered physical therapy (for different reasons) at the same time for the same patient, and there are two separate care plans? (Last Reviewed: June 6, 2008)
Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220.1.2(A), Establishing the Plan, states, "Two Plans. It is acceptable to treat under two separate plans of care when different physician’s/NPP’s refer a patient for different conditions. It is also acceptable to combine the plans of care into one plan covering both conditions if one or the other referring physician/NPP is willing to certify the plan for both conditions. The Treatment Notes continue to require timed code treatment minutes and total treatment time and need not be separated by plan. Progress Reports should be combined if it is possible to make clear that the goals for each plan are addressed. Separate Progress Reports referencing each plan of care may also be written, at the discretion of the treating clinician, or at the request of the certifying physician/NPP, but shall not be required by contractors."
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Physical, Occupational, and Speech Therapy