Question: I work in an outpatient setting and when it's time to do a progress note, I was questioned by my boss as to why I didn't bill for the progress note as a re-evaluation. There were no additional MD orders, and this was strictly a tenth day visit progress note. What is the right way to bill in this case?

Answer:  You were correct to not bill for a re-evaluation in this situation. Progress notes are a summary of the progress that the patient has made to help justify the medical necessity of treatment, and a re-evaluation is typically not warranted. Re-evaluations should be performed in cases where the documentation supports the need for further tests and measurements because there are significant changes in the patient's condition that were not anticipated in the original POT, or the patient is referred for a new condition while still receiving treatment for the original condition. A re-evaluation may also be indicated when the therapist is updating a functional maintenance program. A re-evaluation may also by appropriate when the patient is not making progress as expected, and the therapist feels that the re-evaluation is indicated. Your note should clearly indicate that you have done a re-evaluation, and why the re-evaluation was undertaken.

Re-evaluations should be performed only when the treating therapist feels that it is truly indicated. Therapists should not bill Medicare for a re-evaluation just because it is required by a State Practice Act, Medicaid in your state, or by your facility. Progress notes, just like discharge summaries, are part of the cost of doing business with Medicare.

Question:  We are looking to initiate a group exercise class and have a couple questions. Is there a limit as to the number of patients able to participate in group therapy in an acute care hospital setting? Is there a ratio required for group therapy for patients to therapists?

Answer: There are no rules for the number of participants or therapist: patient ratio for group therapy in an acute hospital setting. However, generally in the acute setting, Medicare does not recognize group as an appropriate mode of therapy; i.e. in the latest Inpatient Rehab Facility guidelines, group cannot be counted to meeting the 3 hour rule.

If you are asking about group therapy in a SNF that is based in your acute hospital, you must follow the rules for SNF Part A, which is that the group can be no larger than 2-4 participants who are focused on the same task or similar activity. In this case, the group must be supervised by a therapist or assistant who is not treating any other patients at the time of the group.

If you are asking about outpatient therapy based in your acute hospital, you must follow rules for Part B. According to Part B rules, a group is 2 or more patients who are being treated concurrently. This excludes the situation where 2 patients are being treated at the same time, but one is receiving a supervised modality (i.e. unattended electrical stimulation) while the other is receiving 1-on-1 treatment by the therapist or assistant. This also excludes the situation where there are 2 patients being treated, but the therapist is providing 1-on-1 therapy and alternating between patients.

Disclaimer: The answers that we provide are based on Medicare guidelines for what is payable under the Medicare Part A and Part B Benefit. As always, the provider should be aware of the other regulations that might supersede the Medicare payment guidelines such as the State Practice Act and the State Administrative Code. In any scenario, the practitioner must go with the most stringent requirement in order to be compliant. The information provided is current as of the time of publication.

If you have a question about Medicare reimbursement you would like the authors to address, send your question and contact information to Medicare Advisor, c/o Lisa Lombardo, ADVANCE for Physical Therapy and Rehab Medicine, 3100 Horizon Dr., King of Prussia, PA 19406; fax 610-275-8562; llombardo@advanceweb.com