Group Coding for Dummies

If you don’t use the group code (CPT 97150) in outpatient physical therapy billing and you dovetail treatments (every :30 minutes) then your company’s behavior sends a message to your employees

The message is this:

We don’t believe our charts and documentation are sufficiently well-written to survive a Medicare (Part B) audit. Also, we aren’t sophisticated or intelligent enough to learn and understand how to correctly code and document the group code.

Fly Below the Radar

Your employees will correctly perceive your corporate compliance strategy is ‘flying below the radar’ – don’t bill it so we don’t get caught. The unspoken secret is that there may be other areas where your Medicare compliance is less than optimum. You would rather give up group code revenue rather than invite suspicion on your other, ‘less risky’ coding patterns.

Rather than give up any revenue why not just learn the appropriate billing strategy and the appropriate way to chart the visit?

The reader can look to the Center for Medicare and Medicaid Services (CMS) Part B PT/OT group coding scenarios at this link: CMS Group Billing Scenarios.

This link has Center for Medicare and Medicaid services official interpretation of many physical and occupational therapy treatment scenarios.

Medicare vs. Everyone Else

What if you bill group code to Medicare patients but not to any other patients?

The Common Procedural Terminology (CPT) codes, created and defined by the American Medical Association (AMA), are not the exclusive province of Medicare. Therefore, you should apply the group code without regard to who pays for the physical therapy service.

The AMA is a professional association that generates revenue from creating, designing and promulgating CPT codes. They don't enforce the codes.

A legal issue probably arises in the insurance contracts that each physical therapist signs with each (non-Medicare) insurance company. The contract may contain language that states the eligible beneficiaries are not to be discriminated from any other patients.

For example, one of my contracts with an insurance company states the following:

"Responsibilities of the Provider:

1) Provide Medically Necessary Health Services to Covered Individuals in a manner similar and within the same time availability in which health care provider provides such services to any other individual and XYZ Co. Provider will not discriminate or differentiate against Covered individuals"

In other words, neither the AMA, the American Physical Therapy Association (APTA) or CMS will care if you treat Medicare patients better than non-Medicare patients. That is, if you are compliant with Medicare ‘rules’ then there are no grounds for CMS to take action.

You may, however, be in violation of your contractual obligations to the insurance company. You may also be in violation of the APTA Code of Ethics.

Principle 2 states the following:

“A physical therapist shall act in a trustworthy manner towards patients and in all other aspects of physical therapy practice”

Principle 3 states this:

“A physical therapist shall comply with laws and regulations governing physical therapy and shall strive to effect changes that benefit patients”

Red Flags

Many of my friends and peers, physical therapists in private practice, have admitted to under-billing the group code because of its perceived ‘red flag’ status.

I think this is a mistake. Know the rules. Follow the rules.

Knowledge is power. Use it.

Tim Richardson, PT