Practice Experience Podcast: Strategies for Billing and Compliance Success

Summer 2024 is trending to be the summer of sequels at the box office—and we certainly don’t want to miss out on a chance to capitalize on a blockbuster. With that in mind, we’re here to revisit last year’s billing and compliance episode with two industry heavyweights not named Godzilla or Kong. 

In this episode of The Practice Experience Podcast, John Wallace, PT, MS, Chief Compliance Officer at WebPT, and Rick Gawenda, PT, President and CEO at Gawenda Seminars and Consulting come together one more to discuss the keys to success in billing and compliance for private practice rehab therapy clinics.

Over the course of the episode, the duo covered a number of topics, including: 

• ethics in dealing with payer differentials and treatment;
• myths surrounding the billing and compliance world; and
• brass tacks to successful billing in today’s private practice.

Episode Highlights: Billing and Compliance Success

On How Many Units a Therapist Should Bill Daily

Rick: The units [alone] can't give an answer without really knowing about the practice. What's their payer mix? What I mean by that is how many of those insurances follow Medicare's eight minute rule versus the rule of eights and substantial portion methodology. Or as you know, John, what's going on a lot now is providers being paid on a per-visit rate—a per diem rate. They just get a flat dollar amount, as long as either your charges or the allowed charges are above the negotiated rate. In that case, you may not want to crank out 3.84 units or four units per visit. Because as long as you probably go two units, maybe three, that's going to get you above that contracted rate.

On the Use of Care Extenders

Rick: I think another piece of it is if your state where you practice allows you to use support personnel to provide therapy under a therapist's direction?

John: We can basically use assistants in all 50 states if you follow the local state rules. But, in addition, there are some states where technicians with direct supervision can bill for services, and there are some states where that's a gray area.

Rick: As we get into the subject, I think it's very important to know not only your state practice act, but also what the payer allows. For example, in your state, perhaps you can use a physical therapy aide or technician to provide patient care services under your direction. But then you also have to look at the insurance company. Does the insurance company allow it as well? If the patient is a Medicare beneficiary, it is not allowed.

On How Seasoned Practice Owners Know How to Use Data

Rick: A seasoned practice owner is one who actually tracks data. This data of course includes units and units per visit and bits of prepaid work hours and many more things that you and I could talk about. From a pure business standpoint, I don't care how much you like that patient. You probably can't afford to work with them one-on-one for 50-60 minutes. So might do what you need to do with them, provide what they need one-on-one, and then say, okay, John, “Go do these exercises I taught you last time.” 

I think practice owners kind of need to look at this stuff and look at their payer mix and which ones are paid per CPT code, which payers are implementing MPPR, which payers are paying a per diem rate, all that. Then base scheduling and productivity off of all these factors.

On the Myth that One-on-One Only Refers to Medicare

Rick: There's the myth out there that the definition of one-on-one only applies to Medicare. The American Medical Association are the ones that create the CPT codes. They own them, and they are copyrighted. So if a CPT code in the CPT book says requires direct one-on-one patient contact, that applies to all payers. For example, if we had two Medicare patients come in at eight o'clock, I think everybody listening today would agree, well, I'm gonna split the time between them. 

Where people make the mistake is, okay, from eight to nine, we're gonna have a Medicare beneficiary and a commercial payer beneficiary. I guarantee most people listening will say, okay, I'm still just gonna put that Medicare patient two units, I'm gonna build that commercial payer four, because the definition of one-on-one does not apply. For the third example, from eight to nine, we have two commercial payers and patients. It's just me. I go back and forth between them for the whole hour, maybe only spending 30 minutes one-on-one with each one. Yet people still bill for full-time because they don't realize the definition of one-on-one applies to all payers, all insurances, not just Medicare.

On Mistakes Made Using the Group Code

Rick:  I think the group therapy CPT code (97150) is the most confusing CPT code out there. When I speak live in front of people, I say it's still so confusing, it takes me six slides to explain it when I'm doing these onsite seminars. People just think because I have two or more patients in my clinic at the same time, and it's just me, it's automatically gonna be group therapy. Well, actually there’s more to it than just that.

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