Medicare Group Treatment Guidelines
For Medicare A:
Group consists of treatment by one therapist to 2 – 4 patients who are performing the same (or a very similar) activity at the same time. The ratio of patients to therapist should not exceed 4:1. Regarding billing:
- Total time patient actively participates in group should be billed, as long as time is a minimum of 15 minutes
- Total group minutes must not exceed 25% of each therapy discipline’s total weekly/assessment treatment time
- Group cannot be supervised by a rehab aide
For Medicare B:
Group consists of simultaneous treatment by one therapist to 2 - 4 patients who may or may not be performing the same activities. The therapist providing group therapy services must be in constant attendance, but one-on-one patient contact is not required.
A therapist may choose to work simultaneously with three Medicare B patients in a 45-minute period, providing intermittent one-on-one contact. The therapist may only bill each patient the number of units of a CPT code according to the time spent providing one-on-one intervention. CMS has provided the following group scenarios for Med B:
- Example A: Two patients are treated over the same 30-minute period; however, 1:1 time occurs with each patient. The therapist should bill the appropriate individual CPT code per patient according to the amount of individual therapy time spent.
- Example B: Two patients are treated simultaneously over the same 30- minute period; however, therapist is dividing time between both patients, providing brief intermittent personal contact . The therapist should bill two group CPT (e.g., 97150* or 92508*) codes per patient.
- Example C: Patient A receives 15 minutes of 1:1 treatment time (8-8:15 am). Patient B comes in, and receives 15 minutes of treatment time. Patient A leaves at 8:30. Patient B remains in 1:1 treatment time from 8:30-8:45 a.m. The Therapist should bill both patient A and B one unit for the direct 1:1 treatment time received, using the CPT code that matches the task performed. Each patient would also be billed one unit for group therapy.
Documentation Guidelines:
If services are provided to a patient as a member of a group, the criteria for coverage requirements for PT, OT and ST must be met. This includes the following:
- Prescription by a physician, based on an active treatment plan (e.g., PT 5x/wk x 4wks for therapeutic activities, gait training and neuromuscular re-education in either group or individual setting)
- Performance by or under the general supervision of a qualified therapist
- Service must be tailored to address each patient’s specific skilled rehabilitation needs
- Follow specific fiscal intermediary (FI) and/or carrier requirements, which may include the need for documentation supporting:
1. Treatment goal addressed in the group
2. Specific treatment techniques utilized during group
3. Group frequency and duration
4. Number of persons in the group
5. Total time spent in a group setting
- Appropriate modifiers and clinical documentation to justify group treatment
- Each resident participating in the group must have an individualized treatment plan for group treatment, including interventions and short- and long-term goals