Humans are naturally social creatures. Being in groups gives us more confidence—and for patients seeking rehab therapy services, that can often lead to better outcomes. But, as a therapist, knowing when and how to bill for one-on-one services (a.k.a. individual therapy) in a group treatment setting can be tricky to say the least. Here are a few things to consider when treating multiple patients during the same timeframe:

9 Most Common Medicare Misconceptions for PTs, OTs, and SLPs - Regular Banner9 Most Common Medicare Misconceptions for PTs, OTs, and SLPs - Small Banner

Billing for Individual Services

In some ways, billing for one-on-one therapy in a group setting seems illogical; I mean, c’mon—can you really provide individualized care within a group setting? While the terminology doesn’t seem to jibe, in reality, it’s a fairly common therapy practice—which is why it’s important for therapists to know how to bill for it appropriately. So, here’s the deal: CMS allows direct one-on-one minutes to “occur continuously (15 minutes straight), or in notable episodes (for example, 10 minutes now, 5 minutes later)”—even if, in between those episodes, the therapist provides group instruction or performs one-on-one treatment with other individuals in the group. However, each individual therapy service “should be of a sufficient length of time to provide the appropriate skilled treatment in accordance with each patient's plan of care.”

Knowing When One-On-One Billing Isn’t Appropriate

Of course, it's also important to know when billing for one-on-one services is not appropriate. Let’s look at an example, as adapted from this APTA resource: four patients—each diagnosed with arthritis—are all scheduled to see their physical therapist at the same time. Because each patient suffers from the same condition, the PT performs a total of 55 minutes of group exercise concurrently with all four patients, including a five-minute rest period after the first 20 minutes of exercise. At the end of the session, the therapist reminds the patients to continue with their home exercise programs as prescribed. In this instance, the group has a common unifying condition (arthritis), and the patients aren’t ever treated on a one-on-one basis. Thus, it would be appropriate to bill group therapy (97150) for each of the four patients.

Applying the 8-Minute Rule

Now that you know when not to bill for one-on-one treatment, here’s an example of when it’s appropriate. Remember, when you’re billing for timed one-on-one services, you must follow the 8-Minute Rule. Here’s how CMS explains it: You have three patients—let’s call them Chico, Harpo, and Groucho—over a 45-minute period. Each patient receives eight minutes of direct one-on-one contact with you for the first 24 minutes. Then, you work directly with Chico for an additional 10 minutes, Harpo for five minutes, and Groucho for six minutes. So, the total amount of direct one-on-one time for each patient is:

  • 18 minutes with Chico
  • 13 minutes with Harpo
  • 14 minutes with Groucho

Thus, you’re allowed to bill each Marx brother—er, patient—for one unit of 97110 (therapeutic exercise). But, because it’s group therapy, you couldn’t bill each patient for three units of 97110.

Using Modifier 59

Finally, when billing one-on-one codes, you should never include a time-based procedure or another constant-attendance modality for the same 15-minute period. Phew, that’s a mouthful, huh? But, to complicate your life just a bit more, that doesn’t preclude you from billing for both group therapy and individual therapy on the same day—as long as:

  1. the group session is clearly distinct or independent from the individual services you provide, and
  2. you apply modifier 59.

It’s your responsibility to determine whether you’re providing linked services or wholly separate services. When the former applies—and the group therapy code forms an edit pair with the one-on-one service code—you can ensure payment for both services by affixing modifier 59 to the appropriate code (check out the chart on this page to determine which code requires the modifier).

Billing for physical therapy services—especially those provided in a group setting—can be tricky. Luckily, you don’t have to go it alone. There’s a wealth of resources (including this blog post) at your disposal. What remaining questions do you have about billing for one-on-one services in a group treatment scenario? Do any issues keep popping up for you? Tell us your thoughts in the comment section below.

  • The PT's Guide to Billing Image

    downloadJun 7, 2016

    The PT's Guide to Billing

    When it comes to physical therapy billing, you have to know your stuff—because even the simplest mistakes can cause denials. Of course, knowing billing backwards and forwards doesn’t have to be complicated. That’s why we created a comprehensive billing resource specifically for PTs. Take the guesswork out of billing. Enter your email address below, and we’ll send your free guide.

  • The Definitive Medicare Part B FAQ for Outpatient PT, OT, and SLP Image

    articleOct 27, 2016 | 33 min. read

    The Definitive Medicare Part B FAQ for Outpatient PT, OT, and SLP

    In October, we hosted a webinar dedicated to the most common Medicare misconceptions . We received a lot of questions from the audience—so many, in fact, that we’ve organized them all into one huge FAQ. Scroll through and check them out, or use the link bank below to skip to a particular section. The Therapy Cap ABNs Modifiers Supervision Prescriptions and Certifications Cash-Pay Rules and Regulations Re-Evaluations Everything Else   The Therapy Cap If a patient reaches …

  • Common Questions from Our PT Billing Open Forum Image

    articleAug 18, 2018 | 34 min. read

    Common Questions from Our PT Billing Open Forum

    Last week, WebPT’s trio of billing experts—Dr. Heidi Jannenga, PT, DPT, ATC/L, WebPT President and Co-founder; John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management; and Dianne Jewell, PT, DPT, PhD, WebPT Director of Clinical Practice, Outcomes, and Education—hosted a live open forum on physical therapy billing . Before the webinar, we challenged registrants to serve up their trickiest PT billing head-scratchers—and boy, did they deliver! We received literally hundreds of questions on …

  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.) Questions …

  • The Ins and Outs of the So-Called Pseudo-Codes Image

    articleNov 29, 2016 | 6 min. read

    The Ins and Outs of the So-Called Pseudo-Codes

    At some point or another, almost every rehab therapist has commiserated with a colleague over the billing process. We know; it’s one of your least-favorite parts of the job. But, while it’s certainly less fulfilling than providing patient treatment, accurately reporting CPT codes is imperative to your ability to get paid. In other words, flubbing up on your billing duties can cost your clinic big bucks—and no one wants to leave cold-hard cash sitting on the table …

  • 2016 Rehab Therapy Year in Review Image

    articleDec 27, 2016 | 10 min. read

    2016 Rehab Therapy Year in Review

    While we’re about to close the books on 2016, we thought it would be nice—and educational—to look back on some of the therapy industry trends, advancements, and hot topics that made headlines throughout the year. Plus, most of these items will impact you and your practice in 2017 and beyond—so, as we look back, don’t forget to look forward. Okay, here we go! Clinical Trends What are those weird suction cups all about? If you, like many …

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

  • 9 Most Common Medicare Misconceptions for PTs, OTs, and SLPs Image

    webinarSep 8, 2016

    9 Most Common Medicare Misconceptions for PTs, OTs, and SLPs

    To say that Medicare regulations are confusing is an understatement. But, it’s not just the barely-readable government gobbledygook that throws providers for a loop; it’s also the fact that the rules are always changing. If you treat Medicare patients, we’re willing to bet you’ve been tripped up by at least one of these common misconceptions—maybe without even knowing it. And that could leave a nasty bruise on your practice’s bottom line—especially if you ever find yourself at …

  • Everything You Need to Know About POPTS Image

    articleNov 26, 2018 | 6 min. read

    Everything You Need to Know About POPTS

    From day one of physical therapy school, we were taught to not even entertain the idea of working for a POPTS practice. I remember hearing the words, “Your license is on the line,” and feeling vaguely scared of the potential fallout from joining one of these heinous practices. But, I was so overwhelmed by the immediacy of school concerns that I didn’t take the time to consider why. I never did work for a POPTS clinic, but …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.