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CMS provides answers to rehab providers when it comes to group therapy

Rehab Regs, July 23, 2003

Source: Briefings on Outpatient Rehab Reimbursement and Regulations, February 2003

As an outpatient rehab provider, do you know how to determine whether you should bill for group therapy or individual therapy when delivering services to patients? More important, do you know how CMS wants you to bill for the services?

You will know the answer to these and other questions once you read a recently released notice from CMS that answers 11 frequently asked questions (FAQs) about group therapy.

Within the past year, one of the hottest issues for outpatient rehab providers-barring the dreaded therapy cap-concerned accurate submission of group therapy claims. The controversial issue sparked so many questions that CMS held a telephone conference call on the subject in September 2002 that drew more than 700 listeners.

In an effort that appears designed to further clarify its policy and answer several of the billing questions received during the conference call, last month the agency released 11 FAQs and answers on group therapy.
Although analysis remains ongoing, the FAQs contain some important clarifications and few surprises with regard to CMS' interpretation of policy, industry experts say.

History of the controversy
Group therapy became a hot topic more than eight months ago when CMS released in May 2002 Transmittal 1753, a clarification of group therapy and student therapy billing for insertion into the Medicare Carriers Manual. The transmittal stated providers can't bill for individual therapy-and receive a higher reimbursement rate-for sessions in which therapists treat more than one patient.

CMS' transmittal immediately aroused protest from those within the rehab community, who argued that the agency's stance actually marked a change in policy.
In an introductory statement on its Web site, CMS notes it received more than 100 questions outlining specific billing scenarios after the telephone conference call. The 11 FAQs released by the agency resulted from its identification of the common principles addressed by the questions. CMS notes that the clarifications do not represent a change in policy and that the statements contained in the questions can be found in a list of supporting manual instructions and criteria.

Although his organization continues to analyze the information contained within the FAQs, Peter Clendenin, executive vice president of the National Association for the Support of Long-Term Care, applauded CMS for the release of the information as FAQs.

"It precludes [CMS] from modifying policy, bringing in some new standard, or setting new policy," Clendenin says. "We've always been on guard that it would bring in a new standard that we'd never seen before, and [CMS said] there's no change in policy."

Where should you focus?
For the average rehab provider, a quick glance at the FAQs may prove overwhelming. But many of the questions are worthy of special attention, says David Ross, CPA, director of reimbursement and internal auditing for Kessler Rehabilitation Corporation in West Orange, NJ. They include the following:

Delivering group and individual therapy on the same day. One of the FAQs addresses an instance in which one patient receives both types of services on the same day. This question did arise in the past for Kessler-which provides outpatient services at several sites and works with many different fiscal intermediaries (FIs). Many times, the answer depended on the FI's individual interpretation.

Submitting claims for more than one group therapy session per day. By addressing whether it's permissible, CMS addressed an unusual occurrence that may, occur for providers from time to time.

Other items worthy of clarification. The FAQs also provide clarification on certain circumstances involving group therapy that, while they may appear clear to many, needed to be issued in writing to ensure that everyone operates on the same page, Ross says.

Group therapy. CMS says that PT, OT, or speech therapies provided to two or more patients at the same time by one practitioner should be billed as group therapy. Those patients can-but do not have to-be involved in the same activity. Although the therapist must be in constant attendance, one-on-one patient contact is not required.

Therapy students. Only services performed by the therapist are subject to Medicare reimbursement. Services performed by those students in the "line-of-sight" supervision of therapists are not reimbursable. Having a student in the room, however, does not make the service "unbillable," the agency says.

The transmittal also addresses issues concerning therapist assistants as clinical instructors, services provided under Part A and Part B, and bad debt collection. Go to www.snfinfo.com/ppsrc/#Therapy to read Transmittal 1872.



Group therapy FAQs worthy of notice

CMS released 11 frequently asked questions and answers concerning group therapy on its Web site. The following question is one of the many worthy of notice, according to industry experts:

Q. Group frequency: How many times can the group therapy code (97150) be billed per patient per day?

A. In private practice settings for physical and occupational therapists, Medicare expects the group therapy code (97150) to be billed only once each day per patient. In the facility 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.

Source: CMS (go to www.cms.hhs.gov/medlearn/therapy and click on "General Information" to access the entire list of questions).

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