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* To restrict or not to restrict?
* How do I properly code for outpatient group therapy?
* Pay-per-view Article: A glimpse into the OIG's crystal ball

Compliance Monitor, January 17, 2003

To restrict or not to restrict?

Q: We have charts at our facility that are considered "restricted" under the Health Insurance Portability & Accountability Act (HIPAA). Covered entities, under section 4.522, must allow patients to request restrictions on the uses and disclosures of their protected health information (PHI). However, a covered entity, does not have to agree to the restriction. On what basis can we deny a patient's restriction request?

A:HIPAA gives no specific guidance on why you could deny such a request. It simply gives a patient the right to request the restriction and you, the covered entity, the right to deny it. The rule also indicates that covered entities must comply with any restriction to which they agree.

Looking further into the regulation, the right to request a restriction is specifically given for

• uses and disclosures for treatment, payment, and health care operations
• disclosures to a friend or family member involved in the patient's care
• disclosures to locate friends or family members and/or to notify them about the patient's location, general condition, or death.

If your policy is to deny restrictions under any circumstance, your patients might view this as an unfair, blanket denial of their right to control the use and disclosure of their PHI. Assuming, however, that you want to be reasonable about approving or denying these requests, here are some options for justifying a denial.

Scenario 1: A patient wants to restrict her PHI, but disclosure is necessary for treatment, payment, and health care operations.

Analysis: You can deny this request, because disclosing PHI allows your staff to effectively deliver and administer care. The disclosure also allows for the reimbursement of that care. It's difficult to think of any situation in which a restriction request wouldn't hinder these basic functions.

Scenario 2: A patient requests a restriction, but disclosure is necessary for a friend or family member who is involved in the patient's care.

Analysis: These types of disclosures are already protected by the HIPAA Privacy regulations, under section 164.510(b). Remember, if the patient is present and able to make health care decisions, you must give the patient an opportunity to agree or object, or infer agreement in your best professional judgment. If the patient is not present or is incapable of making the decision, you must use your judgment and act in the best interest of the patient. Then, disclose only the information that is directly relevant to that person's involvement with the patient. You might deny a request here based on your policy of allowing the patients to agree or object to these disclosures without a formal request from the patient.

A final note: Any other type of requested restriction-for example, to withhold information from the police, from a legal subpoena, or from a worker's compensation report-can be denied because it falls outside of the scope of the HIPAA regulations.

This question was answered by Marion Neal, President of HIPAASimple.com.

Go to "OIG Work Plan: A glimpse into the government's crystal ball" for the rest of this article. The cost is $10. Strategies for Health Care Compliance subscribers have free access via their online subscriptions. Subscribers to the print edition can find this article in their January issues.

A $30 steal!

You can read this article-and much more-in the entire January issue of Strategies for Health Care Compliance. Your cost: Four stories for only $30! You'll find a list of suggested compliance resolutions for 2003, and tips for meeting the HIPAA privacy rule deadline. Also, look for guidance in physician-hospital relationships. Choose between a PDF and HTML version for just $30. Online subscribers have free access to this issue; print newsletter subscribers can find it in their mailboxes. Choose between a PDF and HTML version for just $30. Online subscribers have free access to this issue; print newsletter subscribers can find it in their mailboxes.

Q: What is the appropriate way to use the group therapy code (97150) in an outpatient rehabilitation setting? For example, when we are doing therapeutic exercises with multiple patients at the same time, should we use this non-timed charge (97150), or the time-based code, 97110?

A: Select 97150 for each member of a group when the group is working under constant attendance of the physician or therapist. This is according to the code's definition and instructions in the current procedural terminology (CPT).

When therapists use 97150, they do not report this code representing the specific therapeutic activity. This is not a time-based code.

Here are some tips for using codes 97150 and 97110:

97150:

• When at least two patients undergo therapy simultaneously, report each patient's activity separately using CPT code 97150
• Do not report the CPT code describing the individual therapeutic modality for the activities performed during "group" time

97110:

• This code is time-based and it describes therapeutic services to an individual patient
• To accurately report this code, deliver the service to an individual patient, maintaining constant contact for the time reportedFor example, if the therapist instructs and leads the patient in upper extremity strengthening exercises for 30 minutes, report two units of 97110. If, however, the patient receives this instruction for 15 minutes, and then independently performs the exercises for 15 minutes, report only one unit of 97110 Be sure you are capturing all of the appropriate time if these are the services you are providing to your patient.

Medicare patients:

• Bill only one unit of 97110 if you provided the therapy for a minimum of eight minutes
• Refer to CMS Program Memo AB-00-14 for an additional breakdown of time increments)
• Other payers may define increments differently than the Medicare instruction; therefore, you should query other payers for their interpretation.

This question was answered by Charla Prillman, CPC, CHCO, HCP, a senior associate with PricewaterhouesCoopers.

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