In many cases, physical therapy and occupational therapy go together like peanut butter and jelly. PTs and OTs often share similar goals and interventions, treat the same types of patients in the same settings, and get confused by the billing rules that apply to our respective specialties.
This confusion leads to quite a few questions, including this head-scratcher: how does one bill for OT and PT provided to a single patient on the same day?
While the specifics of billing for PT and OT treatment on the same date of service can be very murky, it’s very possible to do—as long as you color within the lines.
Understand your payers’ rules.
Some payers will reimburse for different service types on the same day, while others will not. So, before you do anything else, confirm your payers’ stance.
Also, there might be specific guidelines attached to your payers’ policies. For example, some insurance companies might reimburse for same-day PT and OT in certain settings (think inpatient rehab or acute hospital settings), but not in others (think outpatient private practice).
This should go without saying, but make sure your services and documentation reflect the fact that you’re providing the treatment best-suited for your patients—no more, and no less.
As we’ll discuss below, Medicare does allow for billing PT and OT in the same day. But there are rules that govern this practice, and they differ depending on whether you’re billing Part A or Part B.
Beware of billing for co-treatment.
Co-treatment can be beneficial for patients and therapists alike, and it might be appropriate if a patient is more likely to reach his or her goals when multiple therapists work together to provide individual treatments during a single session. Therapists often opt to co-treat for safety reasons, but be aware that simply having a second person on hand to act as a contact guard (i.e., to prevent falls) is not enough to justify billing for a second therapist’s services.
Inpatient Rehabilitation Facilities (IRFs)
According to the APTA, therapists who bill under Medicare Part A for services provided in an IRF setting may “bill separately for the distinct services provided at the same time.”
For example, if an OT and a PT co-treat from 10:30 AM to 11:30 AM, and the OT works on toileting strategies while the PT simultaneously addresses safe transfers, both clinicians could bill for that entire hour, provided they show proof of providing separate treatments with separate end goals.
Please note that, per the APTA, “The specific benefit to the patient of the co-treatment must be well documented in the IRF medical record.”
Surprisingly, the inpatient hospital setting does not have a set policy regarding co-treatments, likely because inpatient hospitals are not reimbursed by service, but instead by diagnosis-related groups (DRGs).
Thus, the APTA recommends that therapists follow the same co-treatment rules that apply to IRFs, while again “ensuring that cotreatment is clinically appropriate and provided solely for the benefit of the patient.”
Outpatient Facilities and Private Practices (Part B)
On the other hand, therapists billing under Medicare Part B (i.e, outpatient) cannot bill separately for different (or the same) services provided to the same patient at the same time.
So, even if a PT and OT co-treat a patient with a low functional level in an outpatient setting for safety reasons, they cannot both bill for the entirety of their time. Instead, they must divide up their minutes based on the services each therapist provided.
For example, if an OT and PT co-treat from 10:30 AM to 11:30 AM, the OT can bill for his or her portion of the hour (e.g., 10:30-11:00 AM) under OT codes, while the PT can bill for his or her portion (e.g., 11:00-11:30 AM) under PT codes.
Home Health (Part A)
With regards to home health, according to CMS, “There is nothing that would prohibit a claim from processing with two different disciplines of care being reported on the same day and at the same time.”
So, if your plan of care (POC) indicates that two separate clinicians need to be in a patient’s home—and your documentation supports the medical necessity of both interventions—then both therapists can bill for their individual time.
In other words, the PT and OT should bill as though they were both there on the same day, but at different times.
Skilled Nursing Facilities (SNFs: Part A or Part B)
Things get hairy in the SNF setting, because you have to consider whether your rehab team is billing under Medicare Part A or Part B.
For SNF treatment billed under Part A, an OT and PT can provide different treatments to the same patient at the same time—and each clinician can bill for his or her full treatment session. But again, these co-treatments should be provided on a case-by-case basis according to the needs of the patient—and the documentation must adequately support the reasons for the co-treatment.
Now, for SNF treatment billed under Part B, the rules are similar to those for outpatient settings: the PT and OT cannot both bill for a full session. Instead, they must split the units.
Mind your XP and 59 modifiers.
If your outpatient facility offers OT and PT—and a patient wishes to book separate appointments for each on the same day—then you may need to use a modifier.
Modifier XP is relatively new, and it applies to linked services delivered by different practitioners (for more on linked services, refer to this resource). So, if an OT takes over treatment in the middle of a PT session, the XP modifier would be appropriate.
In other cases—or if the payer does not yet require or recognize X modifiers—modifier 59 may be the appropriate mechanism to identify otherwise linked services that should, given the circumstances, be reimbursed separately. This article provides the following example: “if [the] PT provided gait training (97116) and [the] OT provided therapeutic activity (97530), the billing claim would need Modifier 59 on the 97116 charge to allow for payment of both codes, otherwise, the NCCI edit would only allow payment for 1 code. Since PT and OT were provided at separate and distinct times, Modifier 59 is appropriate.”
Billing has always been tricky, especially when you factor in multiple disciplines. Does your organization bill for co-treatment? Do you have examples to share? Tell us your own billing stories in the comment section below.