Coding Interpretations: Group Therapy Patient Scenarios

Concerns have been raised regarding the delivery of outpatient physical therapy services, specifically regarding the appropriate use of one-on-one codes as opposed to the group code. This page provides APTA's interpretation of the one-on-one and group codes. In addition, it includes patient care scenarios and APTA's analysis of the proper coding of those scenarios. Although these scenarios have been submitted to CMS, APTA has received no response from the agency as to its agreement or disagreement with APTA's interpretations. This page 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 own specific circumstances. 

The AMA's Current Procedural Terminology (CPT) book lists the descriptive terms and identifying codes for reporting medical services and procedures. The purpose of the terminology is to provide a uniform language that will accurately describe medical, surgical, and diagnostic services. The physical medicine and rehabilitation CPT codes are classified as evaluation codes, supervised modalities, constant attendance modalities, therapeutic procedures, and tests and measures. The descriptive language accompanying most of the therapeutic procedure codes requires that the "physician or therapist have direct (one-on-one) patient contact." The descriptive language accompanying the CPT code 97150 (therapeutic procedures, group (2 or more individuals) states that "group therapy procedures involve constant attendance of the physician or therapist, but by definition do not require one-one-one patient contact by the physician or therapist." If further instructs the provider to report 97150 for each member of the group.

Language describing the appropriate use of one-on-one codes and the group code under the Medicare program first appeared in the Federal Register in 1994 (12-8-94, Vol 59, No 235, p. 63451). The same language was republished in the Federal Register in 1996 (11-22-96, Vol 61, No 227, p 59542). CMS further clarified usage of the group code in the Carriers Manual Transmittal 1753, dated May 17, 2002. The language in the transmittal states:

Group Therapy Services (Code 97150)

Pay for outpatient physical therapy services (which includes speech-language pathology services) and outpatient occupational therapy 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 physician or therapist involved in group therapy services must be in constant attendance, but one-on-one patient contact is not required.

Based on this language, it is APTA's understanding that the CPT Code 97150, (Therapeutic Procedure(s), group, (2 or more individuals)) can be applied to different situations under the Medicare program. In one case, the physical therapist, or physical therapist assistant under the direction and supervision of a physical therapist, is simultaneously treating two or more patients whose conditions or treatment have a common, unifying element. For example, the patients might all have had knee surgery; or they might all benefit from specific types of pool exercises; or they might all be part of a class for people waiting to be fitted for lower limb prostheses. The physical therapist might provide some introductory instruction and would remain in attendance for the duration of the session for which a group code was billed.

In another scenario, patients could have diverse conditions and be receiving diverse treatments as part of a group to which the physical therapist gives constant attendance and provides differing, but skilled, services in accord with his or her professional judgment. Patients may perform, in each other's company, individualized exercise routines prescribed by the physical therapist specifically as part of each patient’s plan of care. During the period in which these patients are exercising simultaneously, the physical therapist meets the requirement of constant attendance by providing clinical expertise and judgment 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.

APTA recognizes that in the above situations it may be possible to add the time spent with each individual patient and bill for these services with an appropriate one-on-one code when the one-on-one time requirements are met. This also may be the most efficient approach. However, APTA also supports the interpretation that would allow these professional services to be billed under the group code, which is an untimed code, all other requirements for professional services having been met. The duration of the group session to which the code is applied should be sufficient to ensure that professional ("skilled") services are provided.

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.

Patient Care Scenarios

Assumptions: 

  • These scenarios involve Medicare patients, unless otherwise stated.
  • These scenarios could only be applied if consistent with state law in the state in which they are being applied.
  • According to Medicare regulations, a qualified physical therapist practitioner is a person who is licensed as a physical therapist by the State in which practicing, and who has graduated from a physical therapy curriculum approved by: 1) The American Physical Therapy Association (APTA), or 2) The Committee on Allied Health Education and Accreditation of the American Medical Association, or 3) The Council on Medical Education of the American Medical Association and the American Physical Therapy Association [42CFR484.4]. These regulations also identify criteria for individuals educated as physical therapists before 1966, or who were educated outside the United States. Note: A physical therapist receiving a physical therapy degree on or after January 1, 2002, requires a master's or doctoral degree from a professional physical therapy education program that has been accredited by a national accreditation agency recognized by the United States Department of Education.
  • APTA defines a physical therapist as a person who is a graduate of an accredited physical therapist education program and is licensed to practice physical therapy. The terms "physical therapist" and "physiotherapist" are synonymous.
  • According to Medicare regulations, a qualified physical therapist assistant is a person who is licensed as a physical therapist assistant, if applicable, by the State in which practicing, and 1) Has graduated from a 2-year college-level program approved by the American Physical Therapy Association; or 2) Has 2 years of appropriate experience as a physical therapist assistant, and has achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the U.S. Public Health Service, except that these determinations of proficiency do not apply with respect to persons initially licensed by a State or seeking initial qualification as a physical therapy assistant after December 31, 1977 [42CFR484.4].
  • The APTA defines a physical therapist assistant as a technically educated health care provider who assists the physical therapist in the provision of physical therapy interventions. The physical therapist assistant, under the direction and supervision of the physical therapist, is the only paraprofessional specifically educated to provide physical therapy interventions. The physical therapist assistant is a graduate of a physical therapist assistant associate degree program accredited by the Commission on Accreditation in Physical Therapy (CAPTE).
  • APTA defines physical therapy aides as any support personnel who perform designated tasks related to the operation of the physical therapy service. Tasks are those activities that do not require the clinical decision making of the physical therapist or the clinical problem solving of the physical therapist assistant.
  • Medicare regulations require "personal" (meaning in-room) supervision of PTAs furnishing services in private therapist practices. Medicare requires "general" supervision (meaning periodic inspection and PT availability by telecommunication) of PTAs furnishing services in skilled nursing facilities (SNF), comprehensive outpatient rehabilitation facilities, certified rehabilitation agencies, and home health agencies. Direct supervision (meaning on-premises) is required in physician practices. If states have more stringent PTA supervision regulations than Medicare, then providers must follow state regulations when furnishing services to Medicare beneficiaries.

Disclaimer: These are intended to be examples of proper coding for billing purposes They are not intended to establish a standard for clinical practice. 

1. More Than One Patient in the Clinic

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.

Coding: 

Patient A: 97110 (therapeutic exercise) 2 units; 97014 (electrical stimulation, unattended)

Patient B: 97116 (gait training) 2 units; 97112 (neuromuscular reeducation) 1 unit

Rationale: 

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 rather than 3 units, because there were interruptions during the time frame.

2. More Than One Patient, PT and PTA Providers

Patient A arrives at the physical therapists office at 8:30 a.m. and the physical therapist begins providing Patient A 30 minutes of therapeutic exercise. Patient B arrives for a 9:00 AM appointment and is seen by physical therapist briefly to assess need for modalities. The physical therapist determines that an ultrasound is appropriate to begin the treatment. The physical therapist examines the area to be treated, and directs the physical therapist assistant to position the patient and apply the ultrasound. The physical therapist then begins reviewing patient A's home exercise program. Patient A leaves the clinic at 9:15 AM. At 9:20, patient B's ultrasound is completed. The physical therapist assesses the patient following the application of ultrasound and begins a manual therapy technique to the area. At 9:45 AM patient B begins therapeutic exercises with a physical therapist assistant as instructed and directed by the physical therapist. At 10:00 AM Patient C arrives and the physical therapist begins treatment with 30 minutes of therapeutic exercises, ending with 15 minutes of ice to the area. At 10:15, patient B leaves after completing the therapeutic exercises.

Coding: 

Patient A: 97110 (therapeutic exercise) 3 units

Patient B: 97035 (ultrasound); 97140 (manual therapy) 2 units

97110 (therapeutic exercise) 2 units

Patient C: 97110 (therapeutic exercise) 2 units

Rationale: 

Patient A received three units of therapeutic exercise (97110). Patient A received two units of therapeutic exercise (97110) from 8:30-9:00. After patient B is set up for ultrasound (97035), the therapist continues with Patient A's home exercise program. This time is also billable as a direct one on one service (97110)

Patient B's ultrasound (97035) is a billable service because a physical therapist assistant (supervised by a physical therapist) is attending to Patient B. Patient B then receives manual therapy (97140) from 9:20-9:45, which amounts to two units. Patient B then receives therapeutic exercise (97110) from 9:45 to approximately 10:15, which amounts to two units.

Patient C receives 30 minutes of therapeutic exercise (97110), which amounts to two units. The time during which patient C is getting ice to the area for 15 minutes is not billable as hot/cold packs (97010) are bundled under the Medicare program.

3. Group and One-to-One Procedures

Patients A, B, C and D are scheduled to see their physical therapist at 9:00 AM. They have all recently been fitted with lower limb prostheses. Patients A, B and C are below-knee amputees and patient D is an above-knee amputee. The physical therapist performs ADL training, including stump management techniques with these four patients for 60 minutes. During this 60 minute session, each of the four patients performs return demonstration of the techniques they are instructed in individually (for approximately 10-12 minutes each), with the therapist, one to one, to ensure compliance with the techniques in their home settings.

Coding: 

Patient A: 97535 (self care/home management training); 97150 (group therapy)

Patient B: 97535 (self care/home management training); 97150 (group therapy)

Patient C: 97535 (self care/home management training); 97150 (group therapy)

Patient D: 97535 self care/home management training); 97150 (group therapy)

Rationale: 

Patient A, B, C, and D would be considered as a group with a common, unifying element, therefore a group code (97150) would be billed for each patient. In addition, self care/home management training (CPT code 97535) would also be billed for each patient, because the physical therapist spends approximately 10-12 minutes of one-on-one time with each patient practicing the techniques individually. According to Program Memorandum, AB-00-39, the duration would be appropriate to bill one on one codes.

4. Group Only

Patients A, B, C and D are scheduled to see their physical therapist at 9:00 AM for aquatic therapy with therapeutic exercise. All four patients have arthritis. The physical therapist performs a total of 55 minutes of group exercise with these four individuals, allowing for a 5- minute rest after the first 20 minutes of continuous exercise. During the rest period the patients self-monitor their heart rates as they return to resting and compare their findings to previous sessions. The session ends with the therapist reminding patients to continue to perform their land-based home exercise programs.

Coding: 

Patient A: 97150 (group therapy)

Patient B: 97150 (group therapy)

Patient C: 97150 (group therapy)

Patient D: 97150 (group therapy)

Rationale: 

This is a group with a common unifying element (arthritis). The patients do not receive one-on-one treatment; therefore it is appropriate only to bill the group (97150).

5. Group Combined with Modalities and One-to-One

a. Patients A, B, C are scheduled for physical therapy at 9:00 AM. Patient A is being seen for a recent shoulder dislocation. Patients B and C are both recovering from rotator cuff surgery. After assessing each patient's shoulder, all three patients are provided skilled services simultaneously by the therapist while the therapist is in constant attendance. At 9:20, the physical therapist performs shoulder stabilization exercise techniques with patient A, while patient B and C continue with their strengthening exercises. Periodically the physical therapist will provide verbal cues to patients B and C to assure correct position and speed of their exercises. At 9:35, the physical therapist sets up Patient C on electrical stimulation (unattended) and shortly thereafter, patient A on ice. Following the set up of Patient C and A, the physical therapist performs manual techniques to Patient B's shoulder, while Patient A is receiving ice and Patient C is receiving electric stimulation to the shoulder. At 9:55 the physical therapist reviews Patient C's home exercise program, while Patients A and B perform the upper body ergometer for 10 minutes. Their visits all end at 10:05 AM.

Coding: 

Patient A: 97150 (group therapy); 97110 (therapeutic exercise)

Patient B: 97150 (group therapy); 97140 (manual therapy)

Patient C: 97150 (group therapy); 97014 (electrical stimulation, unattended); 97110 (therapeutic exercise)

Rationale: 

From 9:00-9:20, the patients are receiving group therapy services. The therapist is providing skilled services to all 3, while in constant attendance. Therefore, a group therapy code (97150) would be billed for each patient. From 9:20-9:35 a.m. the physical therapist provides one-on-one services to Patient A, and thus may be one unit of 97110 for Patient A. During that time frame, the physical therapist periodically looks up and makes comments to B and C; however, this time is not counted as billable for B and C, because the therapist is still attending to patient A with his hands during this brief encounter with patients B and C. From 9:40-9:55, patient B receives one-on-one manual therapy, which is therefore billable as 97140. Patient A is receiving ice during this time frame which is not a billable service under the Medicare program. Patient C is receiving unattended electrical stimulation (97014), which is billable as it does not have to be one-on-one. At 9:55, the physical therapist begins working with patient C on modifying and progressing a home exercise program which can be billed as 97110. The time that patient A and B spend performing the upper body ergometer is not billable, because the physical therapist is conducting the home program with patient C.

5b. Patients A, B, C are scheduled for physical therapy at 9:00 AM. Patient A is being seen for a recent shoulder dislocation. Patients B and C are both recovering from rotator cuff surgery. The physical therapist briefly assesses each patient's shoulder and begins shoulder stabilization exercise techniques with patient A, while patient B and C independently initiate their strengthening exercises. Periodically the physical therapist will provide verbal cues to patients B and C to assure correct position and speed of their exercises. At 9:35, the physical therapist performs manual techniques to Patient B's shoulder, while Patient A is receiving ice and Patient C is receiving electric stimulation to the shoulder. At 9:50 the physical therapist reviews Patient C's home exercise program, while Patients A and B perform the upper body ergometer for 10 minutes. Their visits all end at 10:00 AM.

Coding: 

Patient A: 97110 (therapeutic exercise) 2 units

Patient B: 97140 (manual therapy)

Patient C: 97014 (electrical stimulation, unattended); 97110 (therapeutic exercise)

Rationale: 

This scenario differs from 5a in that there is no group charge. The physical therapist would not bill group because there is not the initial 20 minutes with all three patients that occurred in scenario 5a.

Patient A receives shoulder stabilization exercise techniques from approximately 9:00-9:35, which would be considered two units of therapeutic exercise (97110). Periodically, the patient provides verbal cues to patients B and C. However, the time of patient B and C is not billed as either group or one-on-one, because the therapist is working one on one with Patient A. From 9:35-9:50, the therapist is performing manual techniques on Patient B's shoulder which is billable as one unit of manual therapy (97140). During this time frame, Patient A is receiving ice, which is not a billable service under the Medicare program, while Patient C is receiving unattended electrical stimulation (97014), which is billable, because it is not a one-on-one code. At 9:50, the physical therapist begins a one on one service with Patient C, review of the home exercise program that can be billed as therapeutic exercise (97110). However, the 10 minutes spent by A and B performing upper body ergometer is not billable as it is not supervised.

6. Aggregate Time

Patient A arrives for their physical therapy appointment at 9:00 AM. The plan of care is currently focused on the patients need for balance training due to vestibular problems. The physical therapist performs 25 minutes of balance exercises with patient A. The patient rests for 5 minutes. Patient B has arrived for his appointment at 9:20. Patient B, who is being seen for complaints of back pain is seen by the physical therapist initially for 5 minutes of stretching to a tight hamstring. At 9:30 Patient B is instructed to continue stretching as the physical therapist returns to work with Patient A on techniques to improve coordination and balance when transitioning in and out of various postures. At 9:45 patient A and patient B are both on floor mats performing various exercises and stretches to improve movement and coordination. The Therapist provides alternating one to one interventions to both patients A and B for 15 minutes by moving between patients as they progress through their exercises. By 10 AM patient A had received a total of 48 minutes of one-on-one therapeutic interventions, Patient B had received a total of 12 minutes of one-on-one therapeutic interventions.

Coding: 

Patient A: 97112 (neuromuscular reeducation) 3 units

Patient B: 97110 (therapeutic exercise) 1 unit

Rationale 

From 9:00-9:25, patient A receives approximately 25 minutes of neuromuscular reeducation (97112) one on one. The therapist takes a break to see patient B and then moves back and spends more time with Patient A. Neither patient A nor patient B receives group. The one on one time spent alternating back and forth between A and B is incremental and aggregated. Thus, in the end patient A would be billed 3 units of neuromuscular reeducation (97112) and patient B would be billed one unit of therapeutic exercise (97110).

7a. Skilled Group

Five patients are participating in an hour-long exercise program, with constant attendance from a physical therapist. At the beginning of this session, patients locate their exercise program that has been determined for them at a previous visit with their physical therapist. This written program is brought with them as they progress through the various exercise stations. During the period in which these patients are exercising simultaneously, the physical therapist provides clinical expertise and judgment, 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 physical therapist is also there to attend to any patient who may experience difficulty while performing their exercises such as chest pain, dizziness, shortness of breath or other sudden emergencies.

Coding: 

Patient A: 97150 (group therapy)

Patient B: 97150 (group therapy)

Patient C: 97150 (group therapy)

Patient D: 97150 (group therapy)

Patient E: 97150 (group therapy)

Rationale: 

This is an example of a situation in which the therapist is overseeing more than one patient and is providing skilled services to them while in constant attendance. Group therapy (97150) could be billed for each patient in this circumstance.

7b. Supervised Exercise

Eight patients are participating in an hour-long exercise program in a physical therapy clinic. At the beginning of this session, patients locate the exercise program that has been determined for them at a previous visit with their physical therapist. This written program is brought with them as they progress through the various exercise stations available in the gym. Each patient documents the exercise or activity that is completed with the specific parameters performed during that session. The physical therapist intermittently observes these eight individuals during their one-hour exercise period. The physical therapist is available to answer general questions an individual may have regarding the safe use of the equipment. The physical therapist is also there to attend to any patient who may experience difficulty while performing their exercises such as chest pain, dizziness, shortness of breath or other sudden emergencies.

For individual progression or changes to the patients exercise protocol, the patient is directed to the physical therapist that developed the plan for them initially, or the physical therapist that is currently responsible for their plan of care.

Coding: 

Currently in CPT there is no code to appropriately describe the scenario as detailed above.

Rationale: 

This care would not be considered skilled physical therapy and therefore is not a covered service under Medicare. Because it is a noncovered Medicare service, it would be possible for the therapist to collect out-of-pocket payment from the individuals.

8a. One-on-One Followed by Group Intervention (PT & PTA)

Patient A arrives for a 9:00 AM appointment and is seen by the physical therapist for 15 minutes of manual therapy techniques followed by 15 minutes of PNF and manually resistive exercise for strengthening. At 9:15 AM, Patient B arrives and is seen by the physical therapist assistant for 15 minutes of manual stretching. At 9:30, Patient A is seen for 15 minutes of manual stretching by the PTA, while Patient B is seen by the physical therapist from 9:30 to 9:45 for manual therapy techniques. At 9:45, both patients A and B are working in the gym on strengthening exercises previously prescribed by the physical therapist, while the physical therapist assistant supervises both patients, providing verbal, visual and proprioceptive cueing to both patients for correct technique, speed and performance of exercises. Patient A leaves the clinic and 10:15 AM and Patient B leaves the clinic at 10:30 AM.

Coding: 

Patient A: 97110 (therapeutic exercise) 2 units; 97140 (manual therapy); 97150 (group therapy)

Patient B: 97110 (therapeutic exercise); 97140 (manual therapy); 97150 (group therapy)

Rationale: 

Patient A received one on one manual therapy and therapeutic exercise from 9:00 - 9:30. From 9:30-9:45, a physical therapist assistant provides one on one manual stretching, which is billable, because the physical therapist assistant may perform skilled one on one services under the supervision of the physical therapist. This amounts to two units of therapeutic exercise (97110) and one unit of manual therapy (97140).

From 9:15-9:30, Patient B receives manual stretching with the physical therapist assistant (under the supervision of the physical therapist), which is billable. During this time frame, patient B receives 15 minutes of manual stretching, which is counted as a therapeutic exercise (97110) because the physical therapist assistant may perform skilled one on one services. Patient B is then seen by the physical therapist one on one from 9:30-9:45, which may be billed as one unit of manual therapy (97140). Beginning at 9:45 the physical therapist assistant provides skilled services while in constant attendance with Patient A and Patient B simultaneously. Thus, it is appropriate to bill one until of group therapy (97150) for each patient for this time period.

8b. One-on-One Followed by Group Intervention (PT & PT Aide)

Patient A arrives for a 9:00 AM appointment and is seen by the physical therapist for 15 minutes of manual therapy techniques followed by 15 minutes of PNF and manually resistive exercise for strengthening. At 9:15 AM, Patient B arrives and performs a stretching program previously prescribed by the physical therapist for 15 minutes while an aide assists the patient on and off the floor mat. At 9:30, Patient A performs 15 minutes of stretching while an aide assists the patient on and off the floor, while Patient B is seen by the physical therapist from 9:30 to 9:45 for manual therapy techniques. At 9:45, both patients A and B begin working in the gym independently on strengthening exercises previously prescribed by the physical therapist, while an aide assists the patients with getting on and off equipment and checking off the completed exercises on an exercise flow sheet. Patient A leaves the clinic and 10:15 AM and Patient B leaves the clinic at 10:30 AM.

Coding: 

Patient A: 97110 (therapeutic exercise) ; 97140 (manual therapy)

Patient B: 97140 (manual therapy)

Rationale: 

Between 9:00 and 9:30 Patient A receives one unit of therapeutic exercise (97110) and one unit of manual therapy (97140).

The services patient B receives in the stretching program with the assistance of the aide would not be covered services as an aide cannot provide skilled services that would be covered by Medicare.

The time patient B spends one on one with the therapist from 9:30-9:45 would be billed as manual therapy (97140).

This scenario differs from 8a in that there is no group charge. The physical therapist would not bill the group because there is no physical therapist assistant (under the supervision of the physical therapist) providing services in this scenario as there is in 8a. An aide may not supervise group therapy. The time spent by A and B starting at 9:45 in the gym in not billable as the physical therapist is not in constant attendance. The supervision by the aide is not sufficient to permit billing.

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