Medical billing and submitting claims for physical therapy can be a complex process for maximum reimbursement. When it comes to physiotherapy medical billing, there are two kinds of codes, timed and untimed. Knowing the difference between the two and using the correct code is essential for proper medical billing. Following is the comprehensive guide for professional physical therapy billing, including common CPT codes, modifiers, and common errors.
Common Physical Therapy Billing codes
Common physiotherapy billing codes are as follows:
CPT Code 97110
The therapeutic procedure, one or more areas, every 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, and flexibility. It comprises specially designed exercises and activities to help patients gain better mobility and fitness levels. It also involves physical as well as breathing exercises.
CPT Code 97112
Neuromuscular Re-Education: Includes activities that facilitate the re-education of movement, balance, posture, coordination, and kinesthetic sense. The therapeutic procedure also involves or/and proprioception for sitting; or/and standing activities. The physician performs it to reduce impairments and restore function through the application of clinical skills and/or services.
CPT Code 97116
Gait Training: proper ways of various exercises like climbing stairs are instructed to the patient. This training focuses on one or more areas that assist them in walking comfortably and without strain for a period of 15 minutes.
CPT Code 97140
Manual Therapy: Soft tissue mobilization, joint mobilization, manipulation, manual traction, muscle energy techniques, and manual lymphatic drainage. It involves the treatment of soft tissue and joints by controlled pressure and movements.
CPT Code 97150
Group Therapy: The physical therapist provides and supervises the therapeutic procedures to a group (two or more) of patients at the same time, e.g., exercise therapy.
CPT Code 97530
Therapeutic Activities Involve any dynamic activities that are designed to improve functional performance. It requires direct contact with the patient. Use this code for every 15 minutes of activity.
CPT Code 97535
- Self-Care/Home Management Training: Includes a variety of techniques like
- ADL (Active Daily Living) training
- Compensatory training
- Going over Safety procedures/instructions
- Meal preparation
- Use of assistive technology devices or adaptive equipment
- To provide proper instruction to the patient, especially in cases of recovery from acute disease.
CPT Code 97750
Physical Performance Test or Measurement; Includes tests such as the musculoskeletal and functional capacity of the patient. It involves measuring an aspect of physical performance. The provider assesses the patient’s physical performance and completes a written report.
CPT Code 97761
Prosthetic management and training: includes direct one–on–one patient contact. This procedure includes the assessment, fitting, and/or training in the use of a prosthesis. Report this code for each 15 minutes of the initial encounter.
CPT Code 97161
Physical therapy evaluation: low complexity, requiring these components: It involves history to rule out any adverse factors that will affect care and assess one to two elements. Typically involving 20 minutes of face–to–face time with the patient or family or both.
CPT Code 97162
Physical therapy evaluation: moderate complexity; Includes: history to rule out any adverse factors that will affect care and assess three or more elements. It typically involves 30 minutes of face–to–face time with the patient or family or both.
CPT Code 97163
Physical therapy evaluation, high complexity: It typically involves 45 minutes of face–to–face time with the patient or family or both. It also includes the patient’s history with three or more personal factors affecting care and examinations of four or more elements.
CPT Code 97165
Low complexity (97165) An occupational profile and medical and therapy history that includes a brief history, including a review of medical and/or therapy records relating to the presenting problem.
CPT Code 97166
Moderate complexity (97166) An occupational profile and medical and therapy history that includes an expanded review of medical and/or therapy records and an additional review of physical, cognitive, or psychosocial history related to current functional performance.
CPT Code 98940
- Under Chiropractic Manipulative Treatment Procedures
- The provider applies manipulation to influence joint and neurophysiological function by a variety of techniques and modalities in one to two spinal regions.
Timed & Un-Timed Codes for Physical therapy
Billing for Medicare comprises two types of codes, timed and un-timed, for physical therapy.
Timed codes for physical therapy medical billing represent a 15-minute treatment session between the patient and the physician. This type of billing code can be reported multiple times for each session; however, it must include skilled interventions only.
Now because all treatment sessions can’t last 15 minutes each, an 8-minute rule was devised. Based on this 8-minute rule, to bill one unit, the physician must spend a minimum of 8 minutes performing the treatment/activity. Here is how to calculate the number of units, add up the total minutes spent and divide them by 15.
Unlike timed codes, untimed billing codes have no time limit, and a predetermined fee is paid to the physical therapist (irrespective of the time spent). Untimed codes can’t be billed multiple times, and they can only be billed once per treatment session.
Types of Physical Therapy services
Based on the billing codes, physical therapy can be divided into two kinds of services. It includes the one-on-one session between the physical therapist and the patient or group sessions. CPT Code 97150 is to report the group therapy. The code description for billing code 97150 is as follows:
“Group Therapy: The physical therapist provides and supervises the therapeutic procedures to a group (two or more) of patients at the same time, e.g., exercise therapy.”
Modifier 59 & Physical Therapy
There are several modifiers in medical billing, and modifier 59 is one of them. Modifiers in medical billing can make a huge difference, but note that they aren’t meant to change the meaning of the code. For processing the insurance claims, these modifiers provide additional information to improve the accuracy. Modifier 59 in medical billing is used when/if:
“The physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day.” Modifier 59 represents a distinct procedural service.
In physical therapy billing, modifier 59 can be used in several different instances, including the following:
If there is no other suitable modifier available
Using that is the most appropriate way if there is any other more detailed and specific modifier available. Modifier 59 can only be used if no other specific or descriptive modifier is available as a last resort.
Reporting the linked & distinct services
Modifier 59 is one of the most confusing modifiers in medical billing. For physical therapy, this modifier is used to bill two linked or timed codes (e.g., manual therapy & therapeutic activities). Note that it should be used if both the procedures were performed in the same encounter, in the two separate 15-minute intervals. Several physiotherapy services are linked with one another and are commonly performed together, also known as “edit pairs.” And if codes belonging to this edit pair are reported together, only one of them gets reimbursed. This is the reason why modifier 59 should be used for these types of procedure codes so that both of them can be reimbursed. By doing so, your healthcare practice can prevent losing revenues and reimbursements, and the physician is reimbursed for both services.
Other most commonly used modifiers for Physical therapy
- Following modifiers give greater reporting specificity in situations where you used modifier 59 previously:
- Modifier XE
- Modifier XP
- Modifier XS
- Modifier XU
- For representing that the services [were delivered] under an outpatient physical therapy plan of care – Modifier GP
- A modifier for when a patient has reached their physical therapy maximum for the year. The physical therapist must document medical necessity for the continuation of the care if this modifier is used – Modifier KX.
Errors in physical therapy billing services
Several errors or mistakes in medical billing for physical therapy billing services can lead to late payments, lost revenues, and a lower reimbursement rate. However, the risk of errors can be reduced by outsourcing billing to a well-reputed physical therapy medical billing company. Some of the errors include:
Using a non-billable code
Several codes are not billable, meaning they will not be reimbursed if reported. And using these codes can lead to claims being denied or rejected.
Using the incorrect code
Missing digit/alphabet or using an outdated code can lead to the use of an incorrect code in the medical claim. Moreover, use specific and correct codes when billing for the services rendered. For physical therapy, various activities can fall under the code of therapeutic activities. However, more specific codes may exist for the service performed. This is why using that particular code instead of therapeutic activities is essential. Not just this, a specific code can also lead to higher reimbursement.
Documentation plays an essential role in medical billing and revenue cycle management. Moreover, accurate and organized documentation is required in case of claim denials, rejections, or possible audits. The medical necessity behind using a specific code can be justified with complete information. Complete and correct documentation also leads to higher patient satisfaction. On the other side, incorrect documentation can lead to the use of wrong procedure codes, therefore, claim denials.
What is Physical Therapy?
Physiotherapists’ or physical therapists’ primary focus is to restore, maintain, and make the most of patients’ mobility, well-being, and function. The main aim of physiotherapy is to enhance function, relieve pain, improve mobility, and recover or prevent any injuries. There are several reasons why physical therapy is beneficial; some of them include:
Eliminate or reduce pain
- Avoiding surgery
- Improve the mobility
- Prevent any sports injury
- Recover from any sports injury
- Manage diseases like diabetes or vascular conditions
- Manage any medical conditions related to age
- Prevent falls and improve balance and coordination
Frequently asked Questions (FAQs)
1. What is physical therapy billing?
Physiotherapists’ or physical therapists’ primary focus is to restore, maintain, and make the most of patients’ mobility, well-being, and function. Medical billing and submitting claims for physical therapy can be a complex process for maximum reimbursement. Knowing the difference between timed and untimed codes and using the correct code is essential for proper medical billing.
2. What are physical therapy billing errors?
Several errors or mistakes in medical billing for physical therapy billing services can lead to late payments, lost revenues, and a lower reimbursement rate. Some of the errors include:
- Use of non-billable code
- Using an incorrect code
- Incomplete documentation
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