How to bill and code for group therapy
By Marty Kotlar, DC, CHCC

I have several patients perform rehab procedures in a open setting. What is the best way to bill and code for these procedures?

When you have patients performing rehab procedures in an open environment, you need to pay close attention to the CPT codes you submit to insurance companies.

Therapeutic exercise requires direct one-on-one patient contact. In a group setting, however, CPT code 97150 may be more compliant.

Group therapeutic procedures involve constant attendance of the chiropractor (or therapist), but by definition do not require one-on-one contact. If you are dividing attention among patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, then one billing for one unit of CPT code 97150 for each patient is most appropriate.

To illustrate: In a 30-minute period, you work with two patients, A and B, and divide your time between the two patients. You move back and forth between the two patients, spending a minute or two at a time, and provide occasional assistance and modifications to patient A’s exercise program and offer verbal cues for patient B’s therapeutic exercises and balance activities on a gym ball. You do not track continuous or notable, identifiable episodes of direct one-on-one contact with either patient.

The appropriate billing and coding is one unit of 97150 for each patient.

When you provide group therapy:

• Limit the therapy. Group therapy is not covered for more than once a day per patient;

• Limit the number in each group. Any one group should have no more than four patients;

• Document treatments. Documentation requirements include the specific skilled treatments used in the group and how they relate to the plan of care and the number of patients in the group.

Is all the time I spend on providing orthotics for my patients billable?

The time you spend in fitting and training patients for custom-made orthotics is billable under CPT code 97504. This code consists of fitting and training custom-made orthotics to enhance the performance of tasks or movements, support weak or ineffective joints or muscles, reduce or correct joint limitations or deformities, and protect body parts from injury.

Orthotics are often used in conjunction with therapeutic exercise, functional training, and other interventions and should be selected in the context of the patient’s need.

To fit and document the need for orthotics:

• Target the problem. Identify problems in performance of movements or tasks and select the most appropriate device or equipment;

• Fit the device, and train the patient. The goal is for the patient to function at a higher level by decreasing functional limitations or the risk of further functional limitations;

• Document the patient’s need. Document the complexity of the problem to show the medical necessity of using a skilled DC to assess, fit, and instruct;

• Establish and document follow-up visits. Clarify the medical necessity of follow-up assessments of the functioning of the orthotic.

Reimbursement is made only for the clinical time you spend in fitting orthotics and in training the patient to use them properly. You cannot bill for ongoing visits to increase wearing time. These are generally not considered reasonable and necessary when the patient has not experienced any problems.

Nor can you bill for your time and supplies spent in fabricating custom-made orthotics. The supplies and time for fabrication are covered under the respective “L” HCPCS code.

Once the initial fit is established, any further visits should be used for specific documented problems and modifications that require skilled DC advice. These visits are covered under CPT 97703.

It is reasonable and necessary to require one or two visits to fit and educate the patient. If additional visits are necessary, be sure to document the clinical need. Insurers consider more than two visits to evaluate, fit, and teach patients or caregivers unreasonable and unnecessary, unless you have significant documentation to show the necessity.

Note: You can only claim coverage under CPT 97504 for custom-made orthotics — not for prefabricated or commercially made (off-the-shelf) components, such as non-customized supports or wedges. These components do not require the skills of a DC. Minor modifications to prefabricated orthotics do not constitute a custom-made orthotic.

When you document the need for orthotics, include the parameters used in the custom fabrication. If this code is used for the treatment of a lower extremity, CPT 97116 and 97535 are not covered on the same day. Additional documentation requires rationale for use of the orthotics and specific type of orthotic used and area applied. Also list any complicating factors and response of patient to treatment and education.

Marty Kotlar, DC, CHCC, is the president of Target Coding Inc. Certified in Healthcare Compliance, Kotlar has been helping chiro-practors improve reimbursement using proper and compliant CPT coding since 1992. Dr. Kotlar can be reached at: 800-270-7044, www.TargetCoding.com, or drkotlar@targetcoding.com. He is a speaker for the Foot Levelers seminars.