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 therapist or 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, defines and maintains the CPT codes that providers use to submit claims to insurance carriers to be paid for services rendered to their clients. 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, 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 no-fault insurances as well and not just the Medicare program.
Regarding the one-on-one CPT codes, I will use 97035, 97110 and 97530 as examples. In the CPT book, CPT codes 97110 – 97124 fall under the heading of “Therapeutic Procedures”. Under “Therapeutic Procedures”, it states “physician or other qualified health care professional (ie, therapist), required to have direct (one-on-one) patient contact. This means that CPT codes 97110, 97112, 97113, 97116 and 97124 all