Defining One-on-One Therapy for Medicare Patients — Part 1

Please note that this article contains information that is only relevant to American clinics. 


Across America, PTs and OTs are helping people receive the treatment they need thanks to Medicare. But the thing with Medicare is that the government is very stringent when it comes reimbursement for treatments and services rendered.


As a result, this has caused some concern about certain treatment scenarios and whether or not the clinic will be eligible for reimbursement. One of these situations in particular involves the treatment of multiple Medicare patients at the same time. Now, with the help of Gawenda Seminars and Consulting, we’re going to try to dispel all of the rumours and set the story straight.


Is it possible to double-book Medicare patients? Click here to find out.


Generally speaking, all of your Medicare billing is based upon Common Procedural Terminology (CPT) codes. A little known fact, however, is that these CPT codes were created and are maintained by the American Medical Association (AMA). And then, the Department of Health and Human Services designated it as the standard for all electronic claims submissions under the Health Insurance Portability and Affordability Act (HIPAA). In a recent article from Gawenda Seminars and consulting, the author stated that “this means that organizations that submit claims or other health information electronically must use the current year’s CPT codes.”


Hint: Practice Perfect comes pre-loaded with a selection of the most commonly used CPT codes.


Upon closer inspection, you can see that the AMA has used some very specific language when describing the treatment associated with each code. For instance, let’s look at the ‘Constant Attendance’ modality CPT codes.


The AMA states that “the application of a modality that requires direct one-on-one contact.” This means that during this time, the patient must have your complete and undivided attention. If you have two patients in the same room at the same time, you can’t use these codes.


This is largely similar to the language used for ‘Therapeutic Procedures’. At the onset of this section, the AMA states that a “physician or other qualified health care professional (i.e. therapist) are required to have direct one-on-one patient contact”.


So, long story short, if you’re looking for a way to see two Medicare patients at once, you won’t be able to submit claims for both of them if you’re using time-based CPT codes.


Stay tuned for Part 2 where we discuss the nuances of CPT codes and how you can in fact treat multiple Medicare patients at the same time.

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