Can PT billed time exceed time of session?
Dear Help Squad,
I had leg pain and numbness in my right foot. A doctor at DuPage Medical group referred me to physical therapy for treatment of my sciatica.
I had five visits, then the bills started to come in. There was one charge that showed up on the first two appointments but not the last three appointments. When I questioned what the “neuromuscular re-education” cost was, I was very surprised with the answer.
Can DuPage Medical Group really charge a patient $79 for suggesting to roll up a towel and place it behind my back when I sit? Or place a piece of tape down my back to remind me to sit up right?
Please advise on these charges by DuPage Medical Group.
To appreciate just what Gretchen was questioning, it is helpful to understand that physical therapists bill using Current Procedural Terminology (CPT) codes, a standard for coding medical procedures created by the American Medical Association (AMA), that breaks out into two categories: time-based and service-based. All time-based codes must be billed in 15-minute increments. A service-based unit — for services like an examination, applying ice or electrical stimulation — can only be billed as a single unit, regardless of how much time it takes.
Four of Gretchen's 30-minute physical therapy sessions contained three time-based (15-minute) billing units. As such, Gretchen was charged 45 minutes worth of PT services at each of her 30-minute sessions. That was absurd — right?
Per Blue Cross and Blue Shield, the AMA, Medicare and a very helpful website called WebPT, it apparently was not.
I first contacted DuPage Medical Group, where I talked to spokesperson Maria McGowan. She explained that all of DuPage Medical Group's billing is based on universal CPT codes. As for why Gretchen might have been charged three 15-minute billing units for one 30-minute session? McGowan said different types of treatment require different CPT codes. She requested I email her Gretchen's invoice so she could better answer my questions. This I did, followed by two voicemails. I never heard back.
Next, I reached out to Colleen Miller, senior communications manager at Blue Cross and Blue Shield of Illinois. She explained via email that, “(A) unit of (billable) time is attained when the midpoint has passed, based on the guidelines of the AMA and CMS (Centers for Medicaid and Medicare Services). (O)ne 15-minute billed session must be at least eight minutes.”
I asked: If three separate services are performed for eight minutes each at a 30-minute session, can a patient be charged for a total of 45 minutes worth of therapy?
Miller replied: “If three separate services are performed during one visit, a provider can charge for a unit of care for each service.” In other words, yes. She added, “We looked at (Gretchen's) claims and they were processed correctly.”
The WebPT blog post, “The 8-Minute Rule: What It Is and How it Works in WebPT,” offers a detailed explanation of this rather complex billing system, and adds one more caveat: Medicare billing guidelines apply to all insurance companies that accept federal funding. AMA guidelines apply to the rest. Per Medicare, as long as the sum of any incomplete billing units equals at least eight minutes, a therapist can bill for the service with the largest time total, even if that total is less than eight minutes. Under AMA guidelines, “leftover” minutes can be billed only if an individual service totals at least eight minutes.
The short answer to Gretchen's question is yes, DuPage Medical Group can charge a patient $79 for towel rolling advice and tape application — if it takes a minimum of eight minutes to do it.
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