I know Medicare is one on one, but what about all the private insurance companies? How many patients can one physical therapist (or PTA) see at one time and still bill the 97110 code. My employer states that one on one means the patient has to have the ability to receive one on one if needed during the course of their treatment but that several patients can be exercising with the supervision of a therapist and still all be billed for 97110. (for example, if one therapist had 4 patients at the same time and they all did 1 hour of exercise, they could all be billed 97110 for 60 minutes because they all had the ability to receive at least 15 min of one on one from the PT / PTA. Please tell me what you think is legal. I know one on one is always better and I am not looking for a lecture in ethics. I just want something in writing with other therapist's opinions on what they feel is legal so I can give it to my boss.
Number of patients per hour in Outpatient setting
- Thread starter Lillith
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If most of your patients are covered by BCBS, or Aetna, or XYZ, you should look up the billing procedures of that particular company.
Most (if not all) insurance providers would have this sentence in their billing procedures as they all take their cue from CMS:
"Direct one-on-one supervision is required to report [physical therapy] time-based services."
Example: http://www.priorityhealth.com/provider/manual/billing-and-payment/services/physical-therapy
Your boss is really stretching it if he wants you to bill 16 units of therex in the example above. If I were you, I'd start looking for another place of employment.
The sad thing is that your boss is probably not the only one indulging in that kind of fraud.
Most (if not all) insurance providers would have this sentence in their billing procedures as they all take their cue from CMS:
"Direct one-on-one supervision is required to report [physical therapy] time-based services."
Example: http://www.priorityhealth.com/provider/manual/billing-and-payment/services/physical-therapy
Your boss is really stretching it if he wants you to bill 16 units of therex in the example above. If I were you, I'd start looking for another place of employment.
The sad thing is that your boss is probably not the only one indulging in that kind of fraud.
I tried to find that stated in the policy of each insurance company but was unable to find anything that addressed concurrent therapy or stated that services had to be provided one on one. If I had found anything, I would have already given it to him. That is part of the problem. The only information I can find that states services have to be one on one has Medicare attached to it (because they are all based on Medicare guidelines) so he dismisses it as though it only refers to Medicare and no one else. I would love to find something in writing for each insurance company that states this. Another problem is when you call the insurance companies, the representatives don't know anything. Not to come down on anyone but I have called the same insurance company on 3 separate occasions and asked the same questions and received 3 different contradictory answers. Most of them state that since my issue is not addressed directly by their policy manual, it must be ok. And no one, even when I ask to speak to a manager, can tell me for sure what is ok or not when I call.
I wouldn't call, if I were you. Usually the folks who answer phones only have one goal: to get you off the line asap. And there is no record of the conversation; they can very easily deny having told you whatever you heard. In my current line of work (I have a part-time business while in PT school) I deal with federal employees. I never call but always send email or letters instead, to leave a paper trail.
I'd send a letter to the appropriate person in the insurance company and ask him/her point-blank if the practice is acceptable. That will force the respondent to think about it carefully, because it's going to be in writing. Once you have the response, you can take an informed decision about your next action.
I'd send a letter to the appropriate person in the insurance company and ask him/her point-blank if the practice is acceptable. That will force the respondent to think about it carefully, because it's going to be in writing. Once you have the response, you can take an informed decision about your next action.
From what I know and how I practice, your boss is legally correct. You are technically providing direct supervision to all 4 people at the same time while they are doing therapeutic exercise. Your boss is making a killing and pts are not getting best care. Obviously this would be hard to do for a manual therapy unit charge.
When I have 2 private insurance pts in 1 hour, I would bill out 1 manual therapy unit and 3 ther ex/act units x 2. If I had a Medicare pt and private insurance pt in 1 hr, I would bill out 1 manual therapy, 1 ther ex, 1 group charge for the Medicare pt and would only bill 2 units for the private insurance with the other time free of charge.
When I have 2 private insurance pts in 1 hour, I would bill out 1 manual therapy unit and 3 ther ex/act units x 2. If I had a Medicare pt and private insurance pt in 1 hr, I would bill out 1 manual therapy, 1 ther ex, 1 group charge for the Medicare pt and would only bill 2 units for the private insurance with the other time free of charge.
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Yeah...so long as they are private insurance it should be legal. I don't like it and that's why I quit my first OP job, but it's legal.
Ok, then let me ask you this. What is the absolute maximum number of patients one therapist can see at one moment in time? Pretend your coworkers all called off and you had to absorb their caseloads for the day. I know the law is ambiguous as to this and I am asking for industry standard because if it was clearly defined anywhere I would have printed it out for him already. My boss would be perfectly fine if we were to treat 25 patients at one time with one therapist (not that that is the case - I am exaggerating).
Also, what about the medicaid replacement plans - Caresource, Molina, Paramount, and Unison / United Health Care Medicaid Plan? Do they count as "Medicare" or as private insurance?
Also, what about the medicaid replacement plans - Caresource, Molina, Paramount, and Unison / United Health Care Medicaid Plan? Do they count as "Medicare" or as private insurance?
