Does One-on-One Only Apply to Medicare

March 1, 2018
Rick Gawenda

I receive many questions at my in-person seminars and via email that begin something like “I know we can’t have 2 Medicare patient’s being treated at the same time, but how about 2 patient’s with private insurance”? Or, “I know I need to be one-on-one with Medicare patient’s, but that does not apply to patient’s with private insurance, right”? Lastly, “I know if I have 2 Medicare patient’s in my facility for one hour during the same time period, I have to split the time between them, but if the 2 patient’s had private insurance, I could bill each for the entire one hour as one-on-one time, correct”?

I think it is finally time to answer the above questions and put a stop to the myth that you can’t have 2 or more Medicare patient’s in your facility at the same time or that it is okay to bill 2 non-Medicare patient’s for 4 time-based units when they were each in your facility during the same one hour time frame being treated by just one physical or occupational therapist, one physical therapist assistant, or one occupational therapy assistant. The answer, or should I say, where the answer comes from, will surprise many of you. The answer does not come from the Medicare program, private insurance carriers, workers compensation programs, auto no-fault insurance carriers or state practice acts and administrative rules. The answer to all of the above questions comes from the American Medical Association (AMA).

Surprised? I bet you are! How is it that the AMA is the one that provides the answer to the above questions? It is because the AMA is the organization that creates and maintains the Current Procedural Terminology (CPT) codes that providers use to submit claims to insurance carriers, workers compensation carriers and auto carriers to be paid for services rendered to their clients.1 The federal government, Medicare program, and insurance carriers do not create and define the CPT codes; rather, they use the CPT codes as created by the AMA to pay us for our services. So since insurance carriers, workers compensation carriers and auto carriers, not just the Medicare program, use the CPT codes developed and defined by the AMA to pay us for our services, the definition of “direct (one-on-one) patient contact” as defined by the AMA in some of the CPT codes apply to the insurance carriers, workers compensation programs and auto carriers as well, not just the Medicare program.

In addition, in 2000, the CPT code set was designated by the Department of Health and Human Services as the national coding standard for physician and other health care professional services and procedures under the Health insurance Portability and Accountability Act. This means that organizations that submit claims or other health information electronically must use the current years CPT codes.2

Lets begin by looking at the “Constant Attendance” modality codes. Prior to listing the constant attendance modalities, the AMA

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  1. Hello,
    To charge for an PT/OT eval , are there specific criteria that have to be completed. The reason I ask this question because there is some confusion with when not to charge a patient for an eval ; some examples are 1.they cannot charge an evaluation charge unless goals are completed
    2.full examination is done
    3.they cannot charge the patient if they are educating the patient but cannot complete the eval as the patient was inappropriately sent to them.

    Thank you.

    1. The simple answer is yes, there are certain criteria that must be present in an initial evaluation. I would recommend you read your respective state practice act as well as the APTA material regarding documentation.

  2. What about services provided to Tricare and Federal Employee Health Benefit Programs patients at the same time as Medicare patients? Example: Drayer Physical Therapy Institute, LLC settlement for $7,000,000., for service being provided to multiple patients simultaneously as though the service was being provided by a PT or PTA to one patient at a time!?

    1. The definition of one-on-one applies to those insurance carriers as well. Obviously, Drayer did not understand direct one-on-one patient contact if they settled with the OIG.

  3. Sorry if this is a separate question but comes to mind…I was recently told by someone that if a Medicare patient was receiving home health therapy, a consult in an outpatient setting would be a covered benefit (therapy and supplies would not). My understanding was always that if someone was getting home health therapy, they had to be formally discharged before they could begin outpatient therapy. Are you able to clarify?

    1. The Medicare program does not pay for outpatient therapy at the same time there is an open Home Health Agency plan of care.

  4. A question about sensory integration (97533) – seems very hit and miss who denies coverage. Any easier way to obtain a list of payers who do or do not pay?