It can be difficult to figure out how you should be billing Medicare for therapy services, especially if your practice offers both group and individual therapy options. It’s understandable; there are a ton of similarities between the services on both a treatment plan and billing code level.
So, join us today as we compare the differences between billing for group therapy and individual therapy, then review a couple of billing scenarios to make sure that you’re getting reimbursed accurately.
Medicare Coverage Types
As a quick refresher, here are the Medicare Coverage types. Keep in mind that most forms of physical therapy, occupational therapy, speech therapy and applied behavioral analysis are recognized under Medicare Part B.
Medicare Part A |
Helps cover hospital and inpatient costs |
Medicare Part B |
Helps cover outpatient and medical services |
Medicare Part D |
Helps cover the cost of prescription drugs |
Medicare Part C |
Medicare Advantage or “Part C” is a Medicare-approved plan from a private company. These health plans bundle coverage from Part A, Part B and usually Part D. |
Medicare Part B Group Therapy
According to CMS guidelines, group therapy is when a therapist treats two or more patients simultaneously, but does not deliver direct one-on-one contact for a significant amount of time. Regardless if the therapist is splitting their attention among the patients, providing intermittent personal contact or giving the same instruction to multiple patients at once, each patient in that group therapy session should be billed for a single unit of group therapy.
Group Therapy vs. Concurrent Therapy Billing
In the event that a therapist is overseeing treatment for two or more patients that are participating in completely different activities, that would be considered concurrent therapy. While concurrent therapy falls under the group therapy umbrella, it is not recognized under Medicare Part B.
Pros and Cons of Billing for Group Therapy
When it comes to offering group therapy, one of the more obvious benefits is that it’s generally less expensive than individual therapy, which is a very important factor for both patients and providers.
Beyond the advantage of being kinder on the wallet, here’s a brief list of other pros to consider:
- A sense of camaraderie between patients, especially when dealing with injury recovery.
- In the case of applied behavioral analysis (ABA), group therapy can be an important part of developing healthy communication habits and socialization skills with others.
- There may be unique advantages for specific injuries or diseases. For example, in a randomized controlled trial, group physical therapy proved more effective than individual therapy in improving thoracic mobility and overall fitness when managing ankylosing spondylitis, an inflammatory disease that can eventually cause spinal fusion.
On the other hand, a patient participating in group therapy will have to share the attention of the therapist with other patients, possibly sacrificing focused treatment in some sessions.
Individual Therapy
Individual therapy is when direct one-on-one contact is provided in episodes that are of sufficient length (8 minutes or more) to deliver treatment. If a therapist is working with two patients simultaneously, there should be a notable difference in the delivery of care. Without these two criteria met, services rendered might be considered group therapy instead.
Pros and Cons
As with group therapy, individual therapy has its own set of benefits. For example, individual therapy is highly flexible since nearly all forms of therapy can be done one-on-one, whereas group therapy can be a bit more limited. Be sure to keep these additional advantages in mind when considering which form of therapy to prescribe:
- Individual therapy allows for a deeper level of analysis and understanding of the patient, which can result in a much more comprehensive and customized plan of care.
- The therapy can be tailored to the specific client rather than setting a collective group pace that may not be as beneficial to a patient’s individual progress.
- Many patients participating in occupational therapy and applied behavioral analysis may feel more comfortable in a one-on-one setting.
Despite the clear benefits of individual therapy, some clients may have a strong need to identify with other individuals who share similar problems or issues – this need can be best addressed in a group.
Billing Examples for Group Therapy and Individual Therapy
The most obvious difference between group and individual therapy is the amount of time the therapist spends delivering one-on-one contact. It’s incredibly important to effectively report these units of service not only for accurate reimbursement, but to avoid an audit as well! Here are two billing scenarios to help clarify what to bill under if you have multiple clients at the same time:
How to Bill for Group Therapy
In a 25-minute time period, a therapist works with two patients simultaneously. The therapist rotates between the patients, providing short bursts of instruction unique to their plan of care, amounting to only a minute or two at a time. Because there are no “notable, identifiable episodes of direct one-on-one contact with either patient” you would bill each patient for a single unit of group therapy (97150).
Remember: Concurrent therapy is a form of group therapy, but is not recognized by Medicare Part B! In the above example, the two patients would need to be working on similar activities in order to stay out of the concurrent therapy category.
How to Bill for Individual Therapy
In a 45-minute period, a therapist works with 3 patients simultaneously. The therapist cycles between the patients, providing one-on-one contact in 8-minute intervals. After the initial 24 minutes of rotating instruction, the therapist works with each client individually again, bringing the total time spent with each patient to:
- Patient 1: 18 minutes
- Patient 2: 13 minutes
- Patient 3: 14 minutes
At the end of the 45-minute period, the therapist can bill each patient one 15-minute unit of therapeutic exercise (97110).
You may have noticed that none of these three patients actually had exactly 15 minutes of service provided! That’s because services rendered between 8 to 22 minutes are rounded to 15 minutes for billing purposes.
Need a refresher on how units of service are measured? Check out our clinical unit rules resource.
Leverage The Right Billing Software
When it comes to billing, Medicare can be one of the messier places to make a mistake.
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