Medicare Guidelines for Group Therapy

Speech-Language Pathology Services

Reimbursement for group therapy varies based on practice setting and whether the services are covered under Part A (inpatient) or Part B (outpatient). Group therapy policies are further defined in local coverage determinations (LCDs) issued by Medicare Administrative Contractors (MACs). For example, a MAC could define group therapy as no more than four patients, restrict the use of groups to speech-language therapy, and/or allow group therapy for only 25% of the total treatment time per episode. Procedure coding guidelines for group therapy will also vary depending on the MAC.

Documentation for group therapy should clearly

identify why services were delivered in a group setting;
establish that group therapy services were provided as part of an individualized plan of care;
demonstrate that services were based on the clinical needs of the patient; and
describe goals and outcomes (e.g., improvement in the patient’s condition, prevention of further decline).

Group therapy should never be provided for the convenience of the clinician or facility.

Medicare Part A

Medicare Part A covers services provided in inpatient, facility-based settings. Under Part A, group therapy is clearly defined for inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs). For IRFs, the Centers for Medicare & Medicaid Services (CMS) defines a group as 2-6 patients, but has not established any additional policies restricting group therapy. This may change as CMS continues data collection on the use of group therapy in IRFs. In SNFs, group therapy is restricted to 25% of the total treatment time for the patient over the course of an episode. A group must consist of 2–6 patients in a SNF setting.

Medicare Part B

Medicare Part B covers services provided in outpatient settings (e.g., private practice, outpatient clinic) or for services provided to inpatient beneficiaries who have exhausted their Part A benefit. Below are guidelines for group therapy treatment from the Medicare Benefit Policy Manual [PDF] for Part B services.

Medicare Benefit Policy Manual, Chapter 15

230-Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology

A. Group Therapy Services. Contractors pay for outpatient physical therapy services (which includes outpatient speech-language pathology services) and outpatient occupational therapy services provided simultaneously to two or more individuals by a practitioner as group therapy services (97150). The individuals can be, but need not be, performing the same activity. The physician or therapist involved in group therapy services must be in constant attendance, but one-on-one patient contact is not required.

The Medicare Benefit Policy Manual does not establish a specific restriction on the use of group therapy, particularly as it pertains to the size of the group. In the absence of such guidance, speech-language pathologists must refer to the LCD developed by their MAC to determine any such restrictions. LCDs may be accessed through the Medicare Coverage Database.

Coding Considerations

Current Procedural Terminology (CPT © American Medical Association) code 92508 is used to report group therapy for speech, language, voice, communication, and/or auditory processing disorders. There are no CPT codes that describe group therapy for other disorders, such as dysphagia or cognition. However, CPT code 92508 should not be used to report treatment of disorders not described by the code unless specifically permitted under the LCD. Some LCDs may also allow speech-language pathologists to use CPT code 97150 (therapeutic procedure(s), group) to describe group therapy for other disorders, such as dysphagia.

For more information, contact reimbursement@asha.org.