One-on-One Patient Contact and the Use of Support Personnel

By Rick Gawenda, PT*

In the July 2017 of Impact Magazine, I wrote an article titled “One on One: Does It Only Apply to Medicare?” This article then led to requests for clarification from Private Practice Section (PPS) members on how the definition of “requires direct one-on-one patient contact” applies when the physical therapist (PT) is able to use support personnel to provide delegated interventions and procedures to a patient while the PT is simultaneously treating another patient.

The American Medical Association (AMA) is the organization that creates and maintains the Current Procedural Terminology (CPT) codes that providers use to submit claims to insurance carriers, workers’ compensation carriers, and auto carriers to be paid for services rendered to their clients.¹ The federal government, Medicare program, and insurance carriers do not create and define the CPT codes; rather, they use the CPT codes as created by the AMA to pay us for our services. So since insurance carriers, workers’ compensation carriers, and auto carriers, use the CPT codes developed and defined by the AMA to pay us for our services, the definition of “direct (one-on-one) patient contact” as defined by the AMA in some of the CPT codes applies to the insurance carriers, workers’ compensation programs, and auto no-fault insurances as well and not only to the Medicare program.

In their publication CPT Assistant (1999), the AMA, using CPT code 97110 (therapeutic exercise) as the example, stated: “From a CPT coding perspective, code 97110, Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility, requires the therapist to maintain direct patient contact (ie, visual, verbal and/or manual contact) during provision of the service. CPT code 97110 is to be reported when the therapist is providing therapy to only one patient [italics added].”² This same logic would apply to any CPT code that states “requires direct (one-on-one) patient contact.”

In the CPT 2017 Professional Edition the AMA stated: “Physician or other qualified health care professional (ie, therapist) required to have direct (one-on-one) patient contact.”³ This means direct (one-on-one) patient contact not only applies to code 97110, but also CPT codes 97112– 97140 and 97530–97535.⁴

I now want to define support personnel who may be able to provide delegated interventions and procedures under the direction and supervision of a PT. Support personnel could include, but are not limited to, an athletic trainer, exercise physiologist, rehab technician, or rehab aide. I am not including a physical therapist assistant (PTA) in the definition of support personnel since the Medicare program and many third-party payers consider a PTA a qualified practitioner to provide therapy services under the direction and supervision of the PT.

Whether or not a PT can use support personnel to provide delegated interventions or procedures under their supervision depends on 2 factors: their respective state practice act and the insurance carrier. A PT must first look at their state practice licensure law to determine if they are allowed to use support personnel and if yes, what are the supervision requirements of the support personnel and what interventions and procedures can be delegated to the support personnel.

If your state practice act allows you to utilize support personnel, you must then check with the patient’s insurance carrier to determine if they allow support personnel to provide interventions and procedures under the direction of the PT. Both the state practice act and insurance carrier must permit the use of support personnel in order for the PT to delegate interventions and procedures to the support personnel.

Regarding Medicare outpatient therapy services, the Medicare program does not pay for services provided by support personnel, even when directly supervised by the PT. Medicare pays for outpatient therapy services provided by a PT or a PTA under the direction and supervision of the PT.⁵

TRICARE only pays for physical therapy services when the interventions and procedures are provided by a PT. TRICARE does not pay for physical therapy services provided by a PTA or support personnel, even if under the direction and supervision of the PT.⁶

I now want to give several examples to show you how billing would be completed if the PT used support personnel to provide delegated interventions and procedures on a patient receiving outpatient services, while at the same time the PT is treating their own patient, providing skilled therapy services. In all the examples, you need to assume that both your state practice act and the insurance carrier allow for the use of support personnel under the direction and supervision of the PT.

Let’s say a physical therapist is working one on one with a Medicare patient from 10:00 a.m. to 10:15 a.m., providing manual therapy techniques to the right shoulder. During the same time period, from 10:00 a.m. to 10:10 a.m., a rehab technician, under the direction and supervision of the same PT, is providing an ultrasound to a patient whose insurance allows the use of support personnel. The PT would have assessed the patient, determined the need for the ultrasound, and determined the parameters of the ultrasound and the location where the ultrasound is to be applied. In this instance, the PT would be able to bill 1 unit of manual therapy for the time they were working with the Medicare patient and 1 unit of ultrasound that was provided by the rehab technician under the direction and supervision of the PT.

A second example would be a PT treating Patient A for 15 minutes, teaching them strengthening exercises for their right lower extremity, while a rehab technician, during the same 15-minute time period, is working with Patient B doing strengthening and range of motion exercises for the left shoulder. The rehab technician provides technique correction and visual demonstration to Patient B in order for Patient B to do the exercises correctly. This is all done under the direction and supervision of the PT who is treating Patient A. In this instance, the PT would be able to bill 1 unit of therapeutic exercise for the time they were working with Patient A and 1 unit of therapeutic exercise to Patient B that was provided by the rehab technician under the direction and supervision of the PT.

A third example would be a PT treating Patient A, providing manual therapy techniques of joint mobilizations and myofascial release techniques for 15 minutes to the patient’s right shoulder joint while a rehab technician, during the same 15-minute time period, is working with Patient B doing strengthening and range of motion exercises for the left shoulder. The rehab technician provides technique correction and visual demonstration to Patient B in order for Patient B to do the exercises correctly. After the 15 minutes, the PT and rehab technician switch patients, and the PT provides 15 minutes of manual therapy techniques to Patient B while a rehab technician, during the same 15-minute time period, is working with Patient A doing strengthening and range of motion exercises for the right shoulder. The rehab technician provides technique correction and visual demonstration to Patient A in order for Patient A to do the exercises correctly.

In this instance, the PT would be able to bill 1 unit of manual therapy and 1 unit of therapeutic exercise to both Patient A and Patient B. The 1 unit of exercise to each patient can be billed since the rehab technician was providing technique correction and visual demonstration to each patient under the direction and supervision of the PT.

I hope this article has cleared up the misconceptions and myths surrounding one-on-one therapy with patients on Medicare and patients who have private insurance, including the use of support personnel.

References:

¹ American Medical Association. CPT 2017 Professional Edition. 2016;v.

² American Medical Association. CPT Assistant. December 1999;11.

³ American Medical Association. CPT 2017 Professional Edition 2016;668.

⁴ American Medical Association. CPT 2017 Professional Edition. 2016;669.

⁵ CMS Publication 100-02. Medicare Benefit Policy Manual. Chapter 15, Covered Medical and Other Health Services, Section 230.1C. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed August 30, 2017.

⁶ Code of Federal Regulation. Title 32, Subtitle A, Chapter I, Subchapter M, Part 199, Section 199.6. www.gpo.gov/fdsys/ pkg/CFR-2001-title32-vol2/pdf/CFR-2001-title32-vol2-sec199-6.pdf. Accessed August 30, 2017.

Rick Gawenda is the president of Gawenda Seminars & Consulting and a member of the PPS Payment Policy Committee. He can be reached at info@gawendaseminars.com..

* The author has a vested interest in the subject of this article.