One-on-One: Does It Only Apply to Medicare?

February 15, 2016
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 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

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  1. Since we would not be able to bill one-on-one codes for 2 patients being treated at the same time, we would bill group therapy code 97150 for the person(s) not being treated one-on-one but that are supervised, correct?

    1. No, this is not group. I have added another paragraph explaining why it is not group. If you are one-on-one with one patient, you can’t be in attendance of 2 or more people at the same time doing group.

  2. Rick, what about evaluations being done by PT and OT simultaneously? We have an ALS clinic and PT and OT see patient together and this is billed as evaluation code by each discipline. Last time I checked with APTA they said that was OK, but would like your opinion. I know it is different than the article above but have been meaning to get your opinion on this. Thanks

    1. I would agree with APTA and will be writing an article on co-evaluations in the next few weeks.

    1. Thank you! I hope this article helps people and eliminates many of the myths that are out there.

  3. This is a great article – thanks for the clarification. Could you provide the same for modality codes.

    1. The time based modality codes would be the same logic. Un-timed modality codes are service based and are billed for just 1 unit of the applicable CPT code. I addressed that in this article.

  4. By “assistant” do you mean a licensed professional ie PTA or COTA or an unlicensed individual assisting the therapist?

    1. An assistant is a physical therapist assistant or occupational therapy assistant. Rehab aides, rehab techs, athletic trainers, etc. would be considered support personnel.

  5. Do the regulations apply to inpatient rehab facility? So if we use concurrent therapy, do we split the time both patients were seen or can we charge them their respective CPT codes they were seen for i.e. 1 hour session- patient A and B get charged for 30 mins each or 60 mins of individual treatment or neither?

    1. You will want to read the inpatient rehab regulations regarding the 3 hour rule and individual therapy, group therapy and concurrent therapy.

  6. So, if you have two patients at the same time, both doing ther. exs. (97110), can you bill them both since they are not “one-on-one” codes?

    1. Therapeutic exercise is a one-on-one code so you can’t be one-on-one with more than one patient at a time.

  7. As a Rehab Agency – we file as Part A Medicare but are paid under Part B Medicare so when it comes to Medicare patients do we need to only be seeing them one at a time or are we ok with seeing them and then overlapping a commercial patient for the last 30 minutes of the Medicare patients time and still be able to bill?

    1. The definition of one-on-one applies to all outpatient therapy services, regardless of the insurance carrier or how you are set up with the Medicare program and other insurance carriers. You can schedule your patient’s however you want to. What matters is that you bill correctly.

  8. Please consider this patient senario.

    Patient A is a commercial insurance patient
    Patient B is a Medicare beneficiary

    Patient A arrives for PT at 09:00 and works one on one with the PT on manual therapy until 09:20. The patient then continues ther ex with a tech until 10:00. Patient B arrives at 09:20 and works with the PT on ther ex until 10:00.
    Can the PT bill the following? If not what would be the correct billing?
    Patient A: 1 manual, 3 Ther ex
    Patient B: 3 Ther ex

    1. You would first need to review your state practice act and the insurance carriers rules and regulations regarding the use of support personnel (PT tech or PT aide) under the supervision of a therapist. They both must allow it. If yes, the PT would then have to determine if the PT tech, under their supervision and as an extension of them, is providing skilled therapy. If yes, then the PT can bill for the time the PT tech is working with the patient. I would hope the PT tech is not doing 40 minutes of therapy with the patient.

      1. Yes I agree that a tech should not be performing the majority of the session. I was under the impression that if the PT is supervising the tech and working with a Medicare patient, that would constitute charging a group charge since their treatment times overlap.

        1. If you read the article, then you know that is not true. If it were true, it would be true for all insurance carriers and not just Medicare.

  9. Rick, do you know if commercial plan pay for group code. Broad question, but not sure if you had experiences one way or the other

    1. The answer would be it’s insurance carrier specific and you would need to check with each carrier.

  10. In the example above, with the two Medicare patients, one on mechanical traction. it is my understanding that the time used to set up the patient on mechanical traction, supervise activities, cannot be counted toward your direct one to one procedure. So if it takes 5 minutes to set up the mech traction and the remainder of the 15 minutes is spent in ther ex the therapist could bill for both. If it takes ten minutes to set up the patient on mech traction, and five minutes in ther ex, only the mech traction could be billed?

    1. The definition of “direct one-on-one patient contact” in some of the CPT codes apply to all insurance carriers, not just the Medicare program. You would bill the appropriate number of units of the time-based CPT codes based on the amount of time a qualified practitioner was one-on-one with the patient providing skilled services.

  11. Has this information changed? My companies billing and coding expert claims that private insurers and work comp and not held to the same standard as Medicare when it come to ” one on one” codes. It was my understanding from your seminar that ” direct one on one from a qualified provider ” was regardless of payor source for billing purposes.