Group Therapy: Seeing Through the Murky Water?

Fall/Winter 2003

This article was reprinted in Health Lawyers Weekly, February 13, 2004.

Therapy services (physical, occupational, and speech language pathology) are appropriately rendered in either individual or group sessions, based upon the patient's individualized need. This is true in both the inpatient and outpatient setting. Although agreement exists regarding the clinical efficacy of group therapy, there have been differing opinions about what constitutes "group" versus "individual" therapy. Considering the extent to which other payors follow Medicare coverage and payment criteria, the rehabilitation community looks closely at Medicare guidance for rendering group versus individual therapy services.

The dialog regarding Medicare coverage for group therapy began when CMS issued final regulations relating to the physician fee schedule on December 8, 1994. In discussing the methodology for determining payment under the fee schedule, CMS noted:

If the provider did not furnish 15 minutes of one-on-one constant attendance, as the code is defined, he or she may not bill a code for 15 minutes of constant attendance. If the provider is overseeing the therapy of more than one patient during a period of time, he or she must bill the code for group therapy (CPT code 97150), since he or she is not furnishing constant attendance to a single patient.

59 Fed. Reg. 63,410, 63,451 (Dec. 8, 1994). Much of the controversy regarding group therapy began, however, after the May 17, 2002 release of Transmittal 1753, adding section 15302 to the Medicare Carriers Manual. When issuing this transmittal, CMS noted section 15302 was added to clarify CMS's payment policy for group therapy services.

Pay for outpatient physical therapy services (which includes outpatient speech-language pathology services) and outpatient occupational therapy services provided simultaneously to two or more individuals by a practitioner as group therapy services. The individuals can be, but need not be performing the same activity. The physician or therapist involved in group therapy services must be in constant attendance, but one-on-one patient contact is not required.

Medicare Carriers Manual, CMS Pub. 14-3, § 15302.

Group Versus Concurrent Therapy or Dovetailing

Despite CMS's characterization that Transmittal 1753 was not a change in policy, the rehabilitation community was quite concerned that this definition and the way it was being applied by carriers were not consistent with past understandings of what constituted group therapy. Therapy providers understood group therapy to require some commonality of treatment rendered or therapeutic goal to be achieved. For example,

Several patients who had total knee replacement surgery participate in an exercise class where all patients perform the exercises in unison, or
To achieve the goal of independent meal preparation, one patient would cut vegetables for a salad while another patient set the table and a third patient broiled some fish.

Group therapy under this operational premise of commonality was thus distinguished from other types of service delivery whereby a therapist would be working with more than one patient at a time but without any common thread as discussed above. The therapy community utilized the term dovetailing to describe situations lacking commonality, in which a therapist would provide individual treatments to more than one patient at a time.

In response to the number of calls and questions regarding group therapy following the issuance of Transmittal 1753, CMS held a Special Open Door Forum conference call on September 13, 2002. During this call, CMS Administrator Thomas Scully announced the purpose of the forum was to reiterate what CMS believed to be clear policy, rather than to state new or charged policies. Based on CMS's guidance, however, it may seem that the group therapy policy is neither clear nor unchanged.

CMS has attempted, on more than one occasion, to differentiate dovetailing from group therapy. In its discussion, CMS utilizes the term concurrent therapy instead of dovetailing, noting these are synonymous terms. See 66 Fed. Reg. 39,562, 39,567 (July 31, 2001). CMS has defined concurrent therapy as "the practice of one professional therapist treating more than one Medicare beneficiary at a time" and group therapy as a situation in which "all participants ... are working on some common skill development." In other words, CMS notes that group therapy is unlike concurrent therapy in that one beneficiary "likely is not receiving services that relate to those needed by any of the other participants." 66 Fed. Reg. 23,984, 23,991-92 (May 10, 2001). Moreover, CMS acknowledges, "concurrent therapy has a legitimate place in the spectrum of care options available to therapists treating Medicare beneficiaries." 66 Fed. Reg. 39,562, 39,568 (July 31, 2001).

In response to the discussion generated during the September 2002 open door forum, CMS posted a series of questions and answers to its website on January 7, 2003. There, CMS provided the following guidance with respect to group therapy:

Group therapy consists of simultaneous treatment to two or more patients who may or may not be doing the same activities. If the therapist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, it is appropriate to bill each patient one unit of group therapy, 97150 (untimed).

Centers for Medicare and Medicaid Services, 11 FAQs - Post 9/13/02 Open Door on Group Therapy, at cms.hhs.gov/medlearn/therapy/faqinfo.asp.

In response to these more recent pronouncements by CMS, the American Physical Therapy Association (APTA) developed scenarios to illustrate how group therapy versus concurrent individual physical therapy services might be provided. In particular, the APTA did not "interpret Transmittal 1753 as prohibiting payment for a supervised (unattended) modality and a one-on-one service being delivered to two patients in the same time interval." American Physical Therapy Association, Recent Coding Issues and One-on-One and Group Patient Scenarios, at www.apta.org/reimb/coding/cpticd/OneonOne_Group/group_scenarios. Under the scenario given, it is individual, not group, therapy services that are being provided simultaneously to two different patients. In a letter to the APTA dated November 18, 2002, Thomas L. Grissom, CMS Director, confirmed that Transmittal 1753 does not prohibit the provision of concurrent individual therapy as described by this scenario. American Physical Therapy Association, CMS Letter Re: One-on-One Patient Contact and Group Therapy Code, at www.apta.org/reimb/coding/cpticd/OneonOne_Group/cmsletter.

Guidelines for Rendering Group Therapy Services

Many of the details regarding Medicare guidelines for group therapy services appear in training manuals or as commentary included with regulatory changes, making it difficult for a provider to easily understand how to appropriately render group therapy services.

The following bullets highlight some of CMS's general guidelines for all practice settings:

"[R]eceiving PT, OT, or ST as part of a group has clinical merit...." 64 Fed. Reg. 41,644, 41,662 (July 30, 1999).
Although properly supervised licensed or certified therapy assistants may provide group therapy, "a therapy aide must never be responsible for provision of group therapy services, as this is well beyond the scope of services that they are qualified to provide." 64 Fed. Reg. 41,644, 41,661 (July 30, 1999).
Any of the therapeutic procedures identified in CPT codes 97110-97139 may be utilized when providing group therapy services. Am. Med. Ass'n, CPT Assistant 10 (Feb. 1997).
Under Medicare's Correct Coding Initiative, group and individual therapy may be billed on the same day, providing the treatments "occur in different sessions or separate encounters that are distinct or independent from each other when billed on the same day." Centers for Medicare and Medicaid Services, 11 FAQs - Post 9/13/02 Open Door on Group Therapy, at cms.hhs.gov/medlearn/therapy/faqinfo.asp.
Although group therapy is an untimed code, CMS instructs therapists to document in the medical record either the total treatment time or the actual times when therapy started and ended. Such detail is required because "this documented time helps to justify the appropriateness of the services provided." Centers for Medicare and Medicaid Services, 11 FAQs - Post 9/13/02 Open Door on Group Therapy, at cms.hhs.gov/medlearn/therapy/faqinfo.asp.

In addition to general guidelines, CMS has established certain setting-specific requirements. For example:

In the skilled nursing facility setting, group therapy should "not exceed 25% of [the resident's] therapy time." This requirement is only applicable to inpatients covered under a Medicare Part A stay. The 25 percent rule applies separately to each therapy discipline and is based on the aggregate of therapy time during the seven-day MDS assessment observation period. Centers for Medicare and Medicaid Services, Long-Term Care Resident Assessment Instrument User's Manual, 3-188 (ver. 2.0, rev. Aug. 2003).
In the skilled nursing facility, the number of patients to staff may not exceed a 4-to-1 ratio. Id. (This is contrasted to the outpatient setting, in which the payment for group therapy was historically "based on the assumption that the typical group includes five individuals and that the typical group session is of 45 minutes duration." 59 Fed. Reg. 63,410, 63,541 (Dec. 8, 1994).)
In the private practice setting, CMS expects group therapy to be billed only one time per day. This is distinguished from the facility setting, in which "the group therapy code could be applied more than once." Centers for Medicare and Medicaid Services, 11 FAQs - Post 9/13/02 Open Door on Group Therapy, at cms.hhs.gov/medlearn/therapy/faqinfo.asp.