Figuring out how to bill for one-on-one versus group therapy services can be tricky enough that you may need to do some post-bill therapy yourself. But if one thing is clear, it’s that if you offer group therapy services, you should never be billed for a one-on-one CPT code, as doing so increases your risk of being audited by Medicare.
So, what exactly is allowing you to bill (and when)? How do you know if you are offering one-on-one therapy or group therapy? Why is health insurance so complicated, and private insurers even more so? While we don’t have an answer to the last question (sorry!), we can certainly discuss the first two. Let’s start!
What exactly is the difference between one-on-one service and group service?
One-on-one service (also known as individual therapy) refers to direct one-on-one patient contact. The concept of direct patient contact is defined primarily by the American Medical Association (AMA), the organization that created and edited the CPT codes. Therefore, every time the code calls for direct contact (or one-on-one service) with a patient, “face-to-face” time is required. To add a little background information, Medicare plans require that direct contact with a patient occur either “in a row (15 minutes in a row) or during a noteworthy event (eg, 10 minutes now, 5 minutes from now).” The AMA refers to this as intermittent one-on-one.
So if you’re billing with a one-to-one code, you’re telling the payer (whether it’s Medicare or a business plan) that you definitely had a one-on-one with that patient. Additionally, one-to-one CPT codes are cumulative, require ongoing attendance, and are time-based, which means they fall under the 8-minute rule (or AMA’s eight-minute rule). The following is a breakdown of the unit quantities that can be billed based on the total treatment time under the 8-minute rule:
- 8–22 minutes = 1 unit
- 23–37 minutes = 2 units
- 38–52 minutes = 3 units
- 53–67 minutes = 4 units
- 68–82 minutes = 5 units
- 83 minutes = 6 units
Material Disclaimer
Many rehab therapists believe that Medicare handles one-to-one billing differently than other payers. But in fact, it’s not! Since one-to-one time is defined by AMA in the CPT code definition, all payers are subject to the same rules. This means you can’t double bill one-to-one just because you see a patient from a different payer. The exception, of course, is if you work with a therapeutic assistant, technician, or extension within the limitations of the state practice act.
What are group therapy services?
According to CMS, “Group therapy involves simultaneous therapy with two or more patients who may or may not be performing the same activity. Provide only brief, intermittent personal contact if the therapist divides attention between patients , or to give the same instruction to two or more patients at the same time, it is appropriate to charge each patient one unit of group therapy.” As APTA explains, this means that “therapists participating in group therapy services Must be present at all times, but does not require one-on-one patient contact.”
For example, suppose two patients come in for treatment at 10 AM. Mrs Smith suffers from frozen shoulder and Mr Jones is lagging in knee extension after knee replacement. You start your session with Mrs. Smith for 6 minutes, then Mr. Jones for 7 minutes, and so on, roughly the same amount of time with each patient until 10:54 am. At 10:54, you return two patients to demonstrate their home exercise program for 7 minutes. Since the total one-to-one time for two patients is 54 minutes, each patient can be billed as two units of one-on-one, and each person can be billed as one unit of the group code.
Remember that one-on-one time doesn’t have to be continuous and can happen intermittently. The AMA defines “one-on-one” time as: “A physician or other qualified health care professional whose work includes providing skilled services face-to-face with a patient (or caregiver, if applicable). For purposes of determining total service time, the same Intermittent treatment intervals for clinic visits.”
If you’re looking for more group therapy examples, APTA offers this detailed resource with options for both PT and PTA.
Can a therapist charge for one-on-one services when treating multiple patients?
Even if you work with more than one person, you can be billed for one-on-one services if you follow the guidelines in Medicare’s definition of one-on-one time listed above. However, each individual treatment “should be of sufficient length to provide appropriate proficiency in accordance with each patient’s plan of care.” The following are examples of billing scenarios adapted from this APTA resource:
Let’s say you treat three patients (we’ll call them Moe, Larry, and Curly in this article) over the course of 45 minutes. During the first 24 minutes, each patient will have 8 minutes of direct one-on-one contact with you. Then you work directly with Moe for 10 minutes, Larry for 5 minutes, and Curly for 6 minutes. Therefore, the total amount of direct one-to-one time per patient is:
- Moe: 18 minutes
- Larry: 13 minutes
- Curls: 14 minutes
So you can charge each golem (er, patient) a unit of 97110 (therapeutic practice).
Do the rules change if I pay more than one payer?
Well, we know, we know – we’ve fixed that. But this question popped up, and we really wanted to nail down the answer. Leading billing experts agree that therapists should not bill one-on-one codes with other time-based procedures or ongoing office visits that occur within the same 15-minute period. (No double billing, y’all!)
To be clear, this does not prevent you from billing group therapy and individual therapy on the same day – as long as group therapy is clearly distinct or separate from individual services and you use modifier 59. (For more information, check out this Modifier 59 post.)
Hopefully this article has answered at least some of your questions about one-on-one and group services, but as we all know, health insurance is complicated and these are just the basics. See our 8-minute rule, CPT codes, and Medicare guidelines for more details. If you’re completely new to billing, check out our guide to private practice billing.