Medicare Billing Guidelines for Physical Therapy

Medicare covers services rendered by a physical therapist for beneficiaries. Each year there is a limit placed on the amount of incurred expenses the beneficiary may receive. These dollar limits are for physical therapy and speech language pathology services combined.

There are guidelines to billing Medicare for individual and group physical therapy services. Some of the common scenarios for billing physical therapy to Medicare are below.

Expectations

• Medicare expects physical therapists that provide services to patients to spend at least 15 minutes treating the patient. The treatment can either be one on one, group or team. Any services submitted to Medicare for patient care less than 15 minutes will cause further review by the contracting intermediary.

Procedures Not Permitted

• In the same or other 15-minute service, the provider cannot bill that he performed two services (procedures) rendered to the same or to a different patient as:

  a. One-on-one care
  b. Constant attendance
  c. One-on-one care or constant attendance and group therapy
  d. Group therapy that required constant attendance
  e. Untimed evaluation service with a timed procedure

Procedures Permitted

• In the same or other 15-minute service, one therapist may bill for more than one service if she's overseeing more than one patient without providing direct care to either patient at the same time in the capacity of providing supervision to therapeutic exercises for untimed or unattended services. If she does provide some direct one-on-one care to one or more patients during this time, she cannot bill for the direct care time.

Individual Vs. Group Therapy

• To determine whether the physical therapist should bill for individual or group therapy when treating more than one patient at the same time, it must be decided how long the provider spends with each patient he is working with at that time and if he is overseeing any of these patients who are exercising independently.

  Example: One-on-One and therapeutic-exercise service billed

  Therapist is working with two patients in a 30-minute period. Patient A is provided with 10 minutes of one-on-one services. Patient B is then provided with eight minutes of one-on-one service. After the first 18 minutes, patients A and B are working independently on their assigned exercises for 15 minutes each. The therapist can bill one-on-one services at 15 minutes for patients A and B, and 15 minutes of therapeutic exercise for both A and B.

  Example: Group

  The therapist is working with two patients in a 40-minute interval. He provides services to patient A and patient B at the same time. She goes back and forth, providing exercising advice to patient A and helping patient B perform an exercise correctly. He does not record the amount of time spent with each individual patient. Therefore the therapist must bill each patient with one unit of group therapy.

Additional Information

• Medicare expects physical therapy to be provided by a physical therapist and that physical therapy assistants to be qualified by the state and Medicare guidelines to provide care to patients.