Billing Guide For Physical Therapists

You became a therapist to help people improve the quality of their life, however you can’t assist those in need for long if you don’t make enough money for your practice to survive and grow. The billing process is probably the least liked task for physical therapists, yet one that cannot be ignored. Yes, billing can be confusing and sometimes frustrating, but you aren’t alone. StrataPT is always there to help and assist you through your billing and documentation endeavors. When you need a little refresher, please refer to this billing guide prepared just for physical therapists.

Breaking Down The Codes

The International Classification Of Diseases (ICD)

Codes can be confusing and irritating, but they are necessary in order successfully bill for your services. Diagnosing your patients’ conditions in a way that breaks down the medical necessity of those services is accomplished by way of the International Classification of Codes (ICD), which currently is ICD-10.

No two ways about it, the coding system is complex and can be daunting. When in doubt, the American Physical Therapy Association (APTA) recommends that you select the most specific code that most accurately reflects the condition.

The ICD-10 website is a handy resource for all current American ICD-10-CM (diagnosis) and ICD-10-PCS) procedure medical billing codes.

If you are still unsure, please contact StrataPT. Our experienced representatives are always ready to help. We want to see you get it right and get paid on the first submission.

The Current Procedural Terminology

CPT. a registered trademark of the American Medical Association (AMA), is a medical code set that is used to report a medical, surgical or diagnostic procedure and services to entities such as physicians, health insurance companies and accreditation organizations. In other words, it is a language spoken between providers and payers.

CPT was created by the AMA in 1966 to standardize reporting of services and procedures performed in inpatient and outpatient settings. Each CPT code represents a written description of a service or procedure in order to eliminate the subjective interpretation of precisely what was provided to the patient.

CPT codes consist of 5 characters, with the majority of codes being numeric, however, some codes have a fifth alpha character. There is a code assigned for every service or procedure, as well as “unlisted codes” for those services and procedures not specifically named in another defined CPT code.

Because there are such a large number of services and procedures, the AMA organized CPT codes into three category types:

CPT Category I – This contains the largest body of codes. It consists of those commonly used by providers to report their services and procedures (most CPT codes will be Category I codes).

CPT Category II – This category consists of supplemental tracking codes used for performance management.

CPT Category III – These are temporary codes used in reporting emerging and experimental services and procedures.

The six main sections of CPT Category I codes are:

Evaluation & Management Services 99201 to 99499
Anesthesia Services 01000 to 01999
Surgery 10021 to 69990
Radiology Services 70010 to 79999
Pathology & Laboratory Services 80047 to 89398
Medical Services & Procedures 90281 to 99607

Most of the CPT codes that will be relevant to physical therapists will be located in the 97000 section (Physical Medicine & Rehabilitation) of Medical Services & Procedures.

The CPT codes that physical therapists should be most familiar with are as follows:

  • 97001 Physical Therapy Evaluation
  • 97002 Physical Therapy Re-evaluation
  • 97010 Hot or Cold Packs: Application of a modality to one or more areas; hot or cold packs
  • 97012 Mechanical Traction: Application of a modality to one or more areas; traction, mechanical
  • 97014 Electrical Stimulation (unattended): Application of a modality to one or more areas; electrical stimulation (unattended)
  • 97016 Vasopneumatic Device: Application of a modality to one or more areas; vasopneumatic devices
  • 97018 Paraffin bath: Application of a modality to one or more areas; paraffin bath
  • 97022 Whirlpool: Application of a modality to one or more areas; whirlpool
  • 97024 Diathermy: Application of a modality to one or more areas; diathermy (eg, microwave)
  • 97026 Infrared: Application of a modality to one or more areas; infrared
  • 97028 Ultraviolet: Application of a modality to one or more areas; ultraviolet
  • 97032 Electrical Stimulation (manual): Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
  • 97033 Iontophoresis: Application of a modality to one or more areas; iontophoresis, each 15 minutes
  • 97034 Contrast Bath: Application of a modality to one or more areas; contrast baths, each 15 minutes
  • 97035 Ultrasound: Application of a modality to one or more areas; ultrasound, each 15 minutes
  • 97036 Hubbard Tank: Application of a modality to one or more areas; Hubbard tank, each 15 minutes
  • 97110 Therapeutic Exercise: Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, and flexibility. (Generally describes a service aimed at improving a single parameter, such as strength, ROM, etc.)
  • 97112 Neuromuscular Re-education: Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
  • 97113 Aquatic Therapy: Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercise
  • 97116 Gait Training: Skilled improvement of gait, includes stair climbing
  • 97124 Massage Therapeutic: procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
  • 97140 Manual Therapy Techniques: Skilled manual therapy techniques (mobilization, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes. ( PROM is NOT manual therapy)
  • 97530 Therapeutic Activity: Use of dynamic activities to improve functional performance. Describes the activities that use multiple parameters (strength, ROM, balance, etc) together and focus and achieving functional activity.
  • 97535 Self Care / Home Management: Self care/home management training (ADL and compensatory training, meal preparation, safety procedures and instructions in the use of assistive technology devices/adaptive equipment)
  • 97542 Wheelchair Management: Wheelchair Management (eg, assessment, fitting, training), each 15 minutes
  • 97760 Orthotic Management: Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes
  • 97761 Prosthetic Management: Prosthetic training, upper and/or lower extremity(s), each 15 minutes
  • 97762 Orthotic/Prosthetic Checkout: Checkout for orthotic/prosthetic use, established patient, each 15 minutes
  • 97150 Group Therapeutic: procedure(s), group (2 or more individuals)
  • 29530 Knee Strapping
  • 29540 Ankle Strapping
  • 29240 Shoulder Strapping

The CPT Category II codes are arranged as:

Composite Measures 0001F to 0015F
Patient Management 0500F to 0584F
Patient History 1000F to 1505F
Physical Examination 2000F to 2060F
Diagnostic/Screening Processes or Results 3006F to 3776F
Therapeutic, Preventive, or Other Interventions 4000F to 4563F
Follow-up or Other Outcomes 5005F to 5250F
Patient Safety 6005F to 6150F
Structural Measures 7010F to 7025F
Nonmeasure Code Listing 9001F to 9007F

The CPT Category III codes follow Category II codes in the coding manual and are depicted with four numbers and the letter T. Temporary codes describing new services and procedures can remain in Category III for up to five years. If the services and procedures they represent meet Category I criteria (which includes FDA approval, evidence that many providers perform the procedures, and evidence that the procedures have proven effective) they will be reassigned Category I codes. On the other hand, Category III codes can be eliminated if it is determined that providers do not use them.

The AMA release new or revised Category III codes semi-annually via their website and also publishes the Category III deletions annually with the full set of temporary codes.

For more information on CPT codes, please read CPT Codes for Physical Therapy.

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The Use Of Modifiers

CPT modifiers (also known as Level I modifiers) are used to supplement information or adjust care descriptions to provide extra details concerning a procedure or service provided by a physician. Code modifiers help further describe a procedure code without changing its definition.

Here are the modifiers that physical therapists should be most aware of:

Modifier 59 – Modifier 59 should be applied when two wholly separate and distinct services are provided during the same treatment period.

KX Modifier – KX Modifiers should be used when the physical therapist believes it is medically necessary for a patient to continue therapy who has already reached the cap. The KX modifier would qualify the patient for an exemption.

GA Modifier – The GA Modifier is used when the therapist want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on file a properly executed Advanced Beneficiary Notice (ABN) signed by the beneficiary.

GP Modifier – Insurance companies are beginning to require that “Always Therapy” codes be modified to enable accurate reimbursement. The GP Modifier indicates that a physical therapist’s services have been provided. The GP Modifier is commonly used in inpatient and outpatient multidisciplinary settings.

CQ Modifier – The CQ Modifier is used when outpatient physical therapy services are furnished in whole or in part by a physical therapy assistant. Please Note: CMS has announced that starting in 2022, it will only pay 85% of services performed either wholly or in part by a rehab therapist assistant.

For more information about modifiers, please read New PTA and OTA Modifiers Effective January 1, 2020. If you still have questions about modifiers and their mathematical formulas, StrataPT is here to help. We can help you make sense of the when and where to use modifiers, as well as offer revenue cycle management for physical therapy practices with a true all-in-one solution.

Understanding The Terminology

We all need a refresher in billing terminology once in awhile. Here are some common definitions made available from the American Physical Therapy Association (APTA):

  • The 8-Minute Rule: The 8-minute rule is critical for therapists to understand because, according to American Medical Association (AMA) guidelines, leftover minutes that fall into multiple categories with less than 8 minutes per category cannot be billed for. For more comprehensive look into the 8-Minute rule, please read The 8—Minute Rule: A Guide for Therapists and The 8-Minute Rule: Medicare vs, AMA.
  • Medicare Part A Coverage: This includes inpatient hospital, skilled nursing facilities (SNF), hospice and home health. Part A providers also include rehabilitation agencies and comprehensive outpatient rehabilitation facilities (CORF).
  • Medicare Part B Coverage: Part B coverage provides payment for medical supplies, physician services, and outpatient services delivered in a private practice setting (PTPP).
  • Order/Referral: In some instances, a physician will provide an order for therapy that includes a diagnosis and instructions for treatment.
  • Treatment: Includes all therapeutic services.
  • Billable Time: Generally, billable time is the time spent treating a patient. Billable time does not include unskilled prep time, supervision, rest periods and documentation time. Rounding up your time is not allowed either.
  • Timed Codes (constant attendance): These CPT codes allow for variable billing in 15-minute increments when a physical therapist provides a patient with one-on-one services such as therapeutic exercise or manual therapy.
  • Untimed Codes (supervised or service-based): These are the codes therapists use to perform services such as conducting an evaluation, re-evaluation or applying hot/cold packs and electrical stimulation (unattended). You can only bill one code, so it doesn’t matter if you complete these types of treatments in 8 minutes or 48 minutes.
  • Intra-Treatment Time: This code refers to any time spent providing an intervention.
  • Pre-Treatment Time: Assessment and case management are a necessary part of some physical therapy sessions. Physical therapists can bill for this time to assess patient progress, evaluate for injury or muscle deficits or analyzing what approach will be taken during a treatment session under the purview of pre-treatment.
  • Post-Treatment Time: Some time is spent each session analyzing a patient’s response to either an intervention, treatment or giving education or home exercise program. Post-treatment time can also include time spent documenting in the patient’s chart and/or consulting with other healthcare professionals about the patient’s care.
  • Evaluation: The evaluation typically takes place on the patient’s first visit and includes an examination. This consists of a review of historical data and symptoms. Once accomplished, the therapist can provide diagnosis and prognosis. 
  • Re-evaluation: You should only bill for re-evaluation when you note a significant improvement, decline or change in a patient’s condition that was not anticipated in the POC. You can also bill for a re-evaluation if the patient fails to respond to the treatment outlined in the POC, you are treating a patient with a chronic condition and you don’t see the patient very often or if your state practice act requires re-evaluation at specific time intervals.
  • Plan of Care (POC): Based on the evaluation, and the physician’s order (if applicable) the therapist works with the patient to develop a plan of care to help the patient meet their therapeutic goals.
  • Initial Certification: Medicare requires ordering physicians to approve or certify the POC via signature within 30 days of the evaluation. The certification covers the first 90 days of treatment. To continue treatment past the initial 90 days, therapists must receive re-certification from the ordering physician.
  • Progress report: Therapists must complete a progress report (a.k.a. progress note) for every patient by his or her tenth visit.
  • Discharge note: Once treatment is complete, therapists must complete a discharge note that details the patient’s treatment and status since the last progress note.
  • Multiple Procedure Payment Reduction (MPPR): The MPPR applies to therapy and other various ancillary services. The purpose of the Multiple Payment Reduction Policy is to reduce Medicare’s cost for these services. So if a healthcare provider performs multiple procedures during a single patient encounter, Medicare (and many commercial insurers) typically will pay “full price” for only the highest-valued procedure.
  • Telehealth: Telehealth is the delivery of health-related services via telecommunications and digital communication technologies. For more information. Please read E-Visits, Telehealth and MIPS Updates.
  • Patient-Driven Groupings Model (PDGM): PDGM was developed to improve reimbursement for all types of patients eligible for home health benefits and remove perceived incentives to over-provide therapy services. The goal with PFGM is to reduce volume-based reimbursements that doesn’t necessarily align with a patient’s condition and for home health agencies to develop closer, more collaborative relationships with hospitals and skilled nursing facilities. For further reading, please see Understanding PDGM And How It Will Affect Your Physical Therapy Practice.

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Forms To Use

While a few payers still accept paper claim forms, the majority of payers and providers prefer electronic claim forms. Therapists will normally use the CMS-1500 form or the 837P electronic format to submit claims to Medicare contractors for Medicare Part B-covered services (the current 1500 claim forms accommodate ICD-10 codes). Outpatient and partial hospitalization facility claims might be submitted on either a CMS-1500 or a UB-04, depending on the payer.

After services are provided, therapists will submit a bill to either the patient, a third-party payer or claims clearinghouse that will send out the bill on your behalf. If you send out the bill yourself, please make sure you are compliant with HIPPA’s electronic data interchange (EDI) standards.

StrataPT’s software platform makes billing so much easier. And our Strata Clarity Panel provides therapists with clear, real-time status of every single billing charge for every single patient. Schedule a demo today to see how StrataPT help simplify your practice and improve your bottom line.

Choosing A Software

There are a number of companies that provide software for physical therapists, but none can match the level of all-inclusive features and customer support that StrataPT provides. The StrataEMR software platform is extremely intuitive. It provides one system that includes patient intake, scheduling, customizable documentation and an intuitive dashboard to manage your daily tasks and operations. We have the industry-leading technology and cutting-edge tools that sets us apart from every other software company. We also offer a simple pricing structure for our software and revenue cycle management services. Contact us to see how our software can help your practice save time and money.

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