Do Insurance Carriers Pay for Group Therapy

May 30, 2017
Rick Gawenda

Lately, I have been receiving questions regarding group therapy and is group therapy (CPT code 97150 for physical and occupational therapy and CPT code 92508 for speech therapy) payable by the Medicare program and other insurance carriers. Also, people have been asking what’s the difference between group therapy and individual therapy, what are the requirements for group therapy and can I do individual therapy on the same day I do group therapy on a patient.

Lets first talk about Medicare and group therapy in the outpatient setting. The Medicare program does

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  1. How does this work for inpatients? Do you still need a modifier 59. For example, a patient s/p TKR receiving individual PT in the am and group in the pm?

    Thank you

    1. In a true inpatient setting, you are not paid via CPT codes. The Medicare program and most insurance carriers pay via DRG’s. Since not billing CPT codes on the claim form, modifier 59 would not be used.

  2. Rick,
    What is the guidelines for how many patients are allowed in a “group” for billing purposes?

    1. You would have to check with each insurance carrier as well as your Medicare Administrative Contractor to determine if each has limits.

  3. Can you provide any suggestions about documenting group therapy? Is “inadequate gym supervision” sufficient to state the need for using group therapy?

    1. That would not be a reason to bill group therapy. Some things to consider if you really are doing group therapy.
      1. Number of persons in the group
      2. Specific treatment technique(s) used in the group
      3. How the treatment technique will restore function
      4. Frequency and duration of the group setting
      5. Treatment goal in the individualized plan
      6. Why did the treatment have to be provided in a group setting and how would/did the patient benefit from group therapy

  4. With the new BCBS edit software, we are denied for any treatment that requires a CCI edit so all of our codes billed with group, 97150, are denied. Can we just not bill the group code – remove it from billing even though it is part of the patient documentation?
    Thank you.

    1. I would recommend you contact your state therapy association as well as your national therapy association and let them know of the issues.

  5. Is there a code that should be billed for SLP cognitive group? (92508?)
    What about dysphagia?

    1. You would have to check with each insurance carrier to see if they would pay for a cognitive group and if so, what CPT code to use.