January 20, 2009 Bottom Line

Bottom Line: Billing for Co-treatment

Treatments provided during the same session by more than one professional can be looked at in many ways. Determining payment for these services can be complicated by what some call "co-treatment." For example, a child with autism may receive co-treatment from a speech-language pathologist and an occupational therapist. Insurance may refuse to pay for both services even when the co-treatment is considered medically necessary by the health care professionals.

Q: What is the difference between co-treatment and concurrent treatment?

Co-treatment involves more than one professional providing treatment during the same session. Concurrent treatment involves a single clinician treating more than one patient at a time and rendering unrelated services (unlike group therapy).

Q: Under what circumstances is co-treatment clinically appropriate?

Co-treatment is beneficial for some patients, according to Nancy Swigert, 2008 chair of ASHA's Health Care Economics Committee. For example, for a patient with dysphagia, an occupational therapist may address postural control and hand-to-mouth movement while the SLP works on the oral-motor movements for eating. For the most part, however, one professional watches or assists while the other provides the primary care. Such a treatment approach may not be as beneficial as separate treatments by each professional for most patients. For example, Swigert thinks that a patient with apraxia would be better served with individual treatment sessions with each professional. Further, Swigert says, given what we know about motor learning, a child with apraxia would be better served with four 15-minute treatments over four days, rather than one 60-minute treatment from an SLP.

Q: If a patient is seen by an SLP and another professional (e.g., an occupational therapist or psychologist) during the same one-hour visit, how should the visit be billed?

There is no description in the Current Procedural Terminology© (CPT) codebook for concurrent treatment, says R. Wayne Holland, ASHA advisor to the American Medical Association (AMA) CPT Editorial Panel Health Care Professions Advisory Committee. The CPT includes codes only for group or individual treatments. A CPT modifier can be used for reporting by two surgeons performing distinct parts of a procedure, but CPT does not include a related code modifier for other qualified health care professionals.

According to Robert Fifer, ASHA advisor to the AMA/Specialty Society Relative Value Scale Update Committee, billing for co-treatment has been a topic of conversation with Florida Medicaid. He says that the amount of time that can be billed should represent the time that each discipline is devoting to one-on-one patient services. In the case of time overlap by the professionals, only one discipline can bill for that time. Fifer says that there is no such thing as overlapping treatment or co-treatment with regard to billing. If two professionals see the same patient at the same time, only one professional can bill for a service. His response is based on the theory that only one professional is actually providing the service during that period of time. The other professional is either observing or assisting the primary discipline. It is not considered possible for two therapeutic disciplines to provide two different types of therapy at the same time.

Janet McCarty, ASHA's private health plan advisor, says that a key point for co-treatment is billing for the patient's time—rather than the provider's time—in treatment. This rule has also been established by the Medicare program. If an SLP and a physical therapist see a patient at the same time, McCarty maintains that the SLP should bill for the time the patient spends in treatment with the SLP. She goes on to point out that if the patient is seen for a 30-minute session with both an SLP and a physical therapist, the time can be divided: physical therapy for 15 minutes, and speech-language pathology can report CPT 92507 (individual speech and language treatment).

McCarty refers the reader to the Claims Processing Manual on the Centers for Medicare and Medicaid Services (CMS) Web site. CMS offers treatment billing examples, and addresses "team therapy" in which "therapists working together as a team to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient." CMS notes "where a PT and OT both provide services to one patient at the same time, only one can bill for the entire service or the PT and OT can divide the service units. For example, a PT and an OT work together for 30 minutes with one patient on transfer activities. The PT and OT could each bill one unit of 97530 (a code that is billed in 15-minute units). Alternatively, the two units of 97530 could be billed by either the PT or OT, but not both."

Angela Foehl, ASHA director of private health plans, notes that double billing is receiving payment twice for the same treatment time period (session). Foehl adds that if simultaneous services are delivered during a given patient's one-hour session, the allowable billing would be for one session of one hour (split between the providers at one-half hour per provider) if billing rules dictate or allow that method. Note that the SLP's billing portion for speech-language or dysphagia services is almost always reported as an untimed CPT code. However, the shared treatment time must still be billed on a shared basis. Thus, if the session is 50-60 minutes, the other discipline would be allocated 25-30 minutes (which allows billing with two 15-minute untimed codes, if appropriate).

Steven C White, PhD, CCC-A, director of health care economics and advocacy, can be reached at swhite@asha.org.

cite as: White, S. C. (2009, January 20). Bottom Line: Billing for Co-treatment. The ASHA Leader.


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