Doublebooking and Overlapping Medicare Patients
Is this allowed? (Yes!)
By Rick Gawenda*
The Affordable Care Act (ACA) mandates that any provider or supplier enrolled in Medicare, Medicaid, or Children’s Health Insurance Program must implement a compliance program.1
There is a myth I often hear that it’s okay to doublebook and/or overlap physical therapy patients who have private or commercial insurance, workers compensation insurance, and/or coverage under an automobile insurance claim, but it’s not okay to doublebook and/or overlap two Medicare patients for outpatient physical therapy at the same time. In fact, I have actually had physical therapists (PTs) tell me the Centers for Medicare and Medicaid Services (CMS) states somewhere in a CMS manual that you can’t treat two Medicare patients during the same time period for outpatient physical therapy services.
This is a misapprehension (or myth, if you prefer), and the explanation provided here will not only apply to outpatient physical therapy services paid under Medicare Part B benefits but will also apply to commercial and workers compensation carriers, state Medicaid programs, Medicare Advantage plans, and managed Medicaid plans. Keep in mind when I use the word Medicare in this article, this applies only to traditional Medicare Part B beneficiaries and not Medicare Advantage patients.
What we need to remember is no insurance carrier cares or dictates how you schedule their patients for outpatient physical therapy services, and this includes the Medicare program. What insurance carriers, including the Medicare program, do care about is that their patients receive quality and medically necessary physical therapy services and that those services are billed correctly based on the description of each CPT code and the amount of time spent with the patient.
The biggest mistake I find that providers make is that they do not realize the description of the CPT codes that state “requires direct (one-on-one) patient contact” applies to all patients and all insurance carriers, not just the Medicare program. This is because the CPT codes are developed and maintained by the American Medical Association (AMA) and not CMS. So, if a CPT code states “requires direct (one-on-one) patient contact,” the PT or physical therapist assistant (PTA) must be one-on-one with that patient in order to bill that CPT code to any insurance carrier. By submitting a claim form to an insurance carrier where you billed a CPT code that requires “direct (one-on-one) patient contact,” you are attesting that a PT, PTA, or a support personnel, if allowed and under the direction and supervision of the PT, was one-on-one with that patient and that patient only. If not, you are billing incorrectly to that insurance carrier.
Now, let’s answer the question: “Can I doublebook and/or overlap Medicare patients for outpatient physical therapy services?” The answer is yes! For example, let’s say you have two Medicare patients come in at 9:00 a.m. for outpatient physical therapy services; they both leave at approximately 10:15 a.m., and one PT or one PTA will be treating both during this time period.
- The PT or PTA provides 15 minutes of direct one-on-one therapy (therapeutic exercise) to Patient A while Patient B is warming up on the bike. After 15 minutes, the PT or PTA moves over to Patient B to provide 10 minutes of direct one-on-one therapy (manual therapy) while Patient A works under the supervision of the same PT or PTA doing the exercises they were taught.
- The PT or PTA then goes back to Patient A for 10 more minutes of direct one-on-one therapeutic exercise while Patient B works under the supervision of the same PT or PTA doing self-stretching of their quadriceps and hamstrings.
- The PT or PTA then goes back to Patient B for 15 minutes of direct one-on-one therapeutic strengthening exercise while Patient A works under the supervision of the same PT or PTA doing the exercises they were taught.
- Both patients are then placed on unattended electrical stimulation for 15 minutes on their applicable body part for pain reduction.
- Treatment concludes for both patients and they leave the clinic.
In this scenario, the key is the PT or PTA bills the correct number of time-based units based on the amount of time they spent one-on-one with each patient plus any untimed supervised modalities the patient received. The PT or PTA spent 25 minutes of direct one-on-one time with each patient plus each patient received unattended electrical stimulation.
Patient A would get billed 2 units of exercise for the 25 minutes of direct one-on-one time plus 1 unit of unattended electrical stimulation. Patient B would get billed 1 unit of manual therapy and 1 unit of exercise for the 25 minutes of direct one-on-one time plus 1 unit of unattended electrical stimulation. The time the patients were doing their warm-up, supervised exercises and self-stretching without the PT or PTA one-on-one with them is not billable time. There is no CPT code for “supervised exercise.”
This answer would also apply if both patients had commercial insurance, both were workers compensation patients, one patient was Medicare and one patient had a Medicare Advantage plan, one was Medicare and one was a commercial insurance patient, one was Medicare and one was a workers compensation patient, or one was a commercial insurance patient and one was a workers compensation patient. This is because therapeutic exercise and manual therapy each require “direct one-on-one patient contact” in order to bill those CPT codes to the insurance carrier. The key thing to remember is that PT or PTA can only be one-on-one with one patient at a time.
In addition, the time the patients spend exercising and stretching by themselves is not group therapy as the PT or PTA was not in constant attendance of two or more patients providing a skilled service; rather, one patient received one-on-one therapy while the other exercised independently.
At the beginning of this article, I mentioned how PTs have told me that CMS actually prohibits the doublebooking and overlapping of Medicare beneficiaries receiving outpatient physical therapy services. Do you know that CMS actually agrees with me and what I have stated in this article? Just to be clear, CMS states the myth that began this article nowhere in a manual or on their website. In fact, CMS actually states the opposite and provides an example on their website where one PT or one PTA is treating three Medicare beneficiaries during a 45-minute period and how to bill the appropriate number of time-based units to each Medicare beneficiary based on the amount of minutes spent one-on-one with each Medicare beneficiary. To access this example, go to https://cms.gov/therapyservices and then click on “11 Part B Billing Scenarios for PTs and OTs (Individual vs Group Treatment) and then read question and answer to #3.1
Finally, you may want to ask which CPT codes most commonly used by PTs and PTAs require direct (one-on-one) patient contact? They are CPT codes 97032–97036, 97110–97140, and 97530–97537.2
1Centers for Medicare and Medicaid Services, Therapy Services, 11 Part B Billing Scenarios for PTs and OTs (Individual vs Group Treatment). https://www.cms.gov/Medicare/Billing/TherapyServices/index.html?redirect=/therapyservices. Accessed May 30, 2019.
2Current Procedural Terminology 2019, Professional Edition, American Medical Association. 2018; 728-730.
Rick Gawenda is the president of Gawenda Seminars & Consulting and a member of the PPS Payment Policy Committee. He can be reached at firstname.lastname@example.org.
*This author has a professional affiliation with this subject.