Re: Elaphant in the room

[Guest guest]

,

I'm copying and pasting considerations relating to the practice and billing for

physical therpay services. I reference Texas when speaking about State practice

act rules. Your state rules may be different.

Three parameters guide the practice of physical therapy:

1. State Practice Act Rules. The practice of physical therapy must follow the

State Board of Physical Therapy Examiners Physical Therapy Rules. Texas for

example, allows for the use of care extenders (aides) in the delivery of

physical therapy services. The number of aides that can be utilized per

physical therapist is up to the professional discretion of the therapist.

(§322.3. Supervision. (a) Page 5, April 2009)

2. National Association (APTA) Guide for Professional Conduct. The American

Physical Therapy Association has set forth a Guide for Professional Conduct.

This Guide for Professional Conduct (Guide) is intended to serve physical

therapists in interpreting the Code of Ethics (Code) of the American Physical

Therapy Association (Association), in matters of professional conduct. The Guide

provides guidelines by which physical therapists may determine the propriety of

their conduct. The Code and the Guide apply to all physical therapists.

3. Contractual Agreements with Third Party Payers. When a provider enters into

an agreement with a third party payor, that provider must adhere to the specific

guidelines as set up in the agreement. Contractual agreements, as in the case

of Medicare, may be more restrictive than rules set forth in the State Practice

Act. For example, Medicare Part B specifically prohibits the use of

non-licensed personnel in the delivery of billable physical therapy services

whereas the Texas Practice Act allows for their use. The default is to the more

restrictive of the two (Contractual agreement and State Practice Act Rules). If

the contractual agreement does not specifically prohibit the use of aides, you

would defer to the State Practice Act rules. An additional consideration would

be AMA's CPT billing definitions (one-to-one vs. group).

What services can a physical therapist bill for? The Current Procedural

Terminology (CPT) guidelines set by the American Medical Association define what

services can be billed by the physical therapy profession. These definitions

are found on page 439 of the 2009 CPT book under Physical Medicine and

Rehabilitation section. These definitions are grossly categorized as follows:

A. 97001 – 97006: Evaluations

B. 97010 – 97039: Modalities; Modalities are subdivided to Supervised

(97010-97028) which do not require direct (one-to-one) patient contact by the

provider and Constant Attendance (97032-97039) which do require direct

(one-to-one) patient contact by the provider.

C. 97110 – 97546: Therapeutic Procedures: CPT definitions specify that the

Physician or therapist is required to have direct (one-to-one) patient contact.

The only exception to this is for 97150 Group Therapy. Group therapy is defined

as 2 or more individuals being treated at the same time (page 440). Group

therapy procedures involve constant attendance of the physician or therapist,

but by definition do not require one-on-one patient contact by the physician or

therapist.

D. 97597 – 97606: Active Wound Care management: Provider is required to have

direct one-on-one patient contact.

E. 97550 – 97755: Tests and Measurements: Requires direct one-on-one patient

contact.

F. 97760 – 97799: Orthotic Management and Prosthetic Management: No definition

of one-to-one.

G. 97799: Other Procedures: Defined as Unlisted physical

medicine/rehabilitation service or procedure.

What are the clinical implications for `Supervised' and `Constant Attendance'

for the CPT code ranges 97010 – 97028?

A. Supervised modalities: 97010 (Hot/Cold Packs), 97012 (Traction), 97014

(Electrical Stimulation), 97018 (Paraffin Bath), etc. do not require direct

one-to-one patient contact by the provider. Therefore, these modalities can be

administered to a patient (and billed for) while the PT/PTA/Aide is working with

another patient.

Patient Scenario: 1 PT with 2 patients (one patient receiving traction and

one patient receiving one-to-one exercises with the PT. This scenario is not

considered group per CPT definitions.

B. Constant Attendance modalities (97110-97546): Services such as 97110

(Therapeutic Procedure/Exercise) require direct one-to-one patient contact by

the provider. One-to-one direct contact can take many forms per the State

Practice act (Contractual agreements may be more strict in this interpretation)

as follows:

i. 1 PT to 1 patient

ii. 1 PTA to 1 patient

iii. 1 Aide to 1 patient

** Any ratio greater than 1:1 with the exception of supervised modalities is

defined as a Group Therapy per AMA CPT Definitions (2009: page 404).**

4. What constitutes Group Therapy?

A. Group Therapy as defined by the AMA in the 2009 CPT book (page 440) is 2 or

more individuals being treated at the same time. Group therapy procedures

involve constant attendance of the physician or therapist, but by definition do

not require one-on-one patient contact by the physician or therapist.

B. APTA's position on One-to-One and Group codes under Medicare is at the

following link:

http://www.apta.org/AM/Template.cfm?Section=Home & CONTENTID=48773 & TEMPLATE=/CM/Co\

ntentDisplay.cfm

Hope this helps.

Jon Mark Pleasant, PT

Methodist Medical Center

>

> I am looking for clarification regarding rules and regulations. We

> are a PT owned private practice with three PTs, three PTAs and one

> tech. The tech duties are primarily set up and clean up. It has come

> to my attention that other clinics are utilizing techs to provide

> greater levels of care. For example, a soul PT with two techs

> managing 23 pts per day. How is this legally possible? Another clinic

> having techs providing supervised exercise and ultrasound and billing

> for these services. Now I am clear this is against Medicare

> regulations and I was under the impression that the same regulations

> applied to all insurance providers. Either I am wrong or a number of

> clinics are pushing the boundaries. Could the group offer me some

> feedback?

>

> DuBois PT, GCS

> on & DuBois Momentum Physical Therapy, LLC

> Tucson, AZ.

> mdptgcs5@...

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