Medicare Fee Calculator

Related:

• Physical Therapy Practice Benchmarks
• Healthcare Payer Reimbursement Rates
• Patient Benefit Verification Guide
• ROI Calculator

How is Medicare Reimbursement Calculated?

Our Medicare Fee Calculator is a free tool to help you work out how much you can expect to be reimbursed for the treatment you issue.

It’s simple. You can find out how much your practice is owed in four steps:

1. Select your locality from the dropdown menu. If you’re not sure what to choose, check out the list on the CMS site.
2. Choose whether an assistant was involved in delivering care. This will affect how much you’re reimbursed.
3. Select the relevant CPT code and the number of units. If more than one code is relevant to your encounter with a patient, you can add as many additional charges as you need.
4. See how much you can expect to be reimbursed. Our calculator will give you an up-to-date reimbursement rate based on your locality and treatment.

Medicare reimbursement rates are typically set at 80% of the cost of providing services. (That’s because the patient will be responsible for the remaining 20%). There are some specific services whose rates might be higher or lower, but for physical therapy, 80% is the typical reimbursement rate.

You’ll notice that reimbursement rates can differ dramatically by location, so it’s good to make sure that you’ve selected the correct locality from the list.

If you select more than one unit of a single code, for every subsequent unit you’ll only receive a fraction of that code’s full value. This is known as Multiple Procedure Payment Reduction (MPPR). It doesn’t apply to all codes—only those known as “always therapy” services.

Reimbursement rates are reviewed annually based on many different factors and the Medicare fee schedule is updated in line with the recommendations of a panel of experts. Our Medicare Fee Calculator uses the most up-to-date fee schedules, so you can trust the results.

Medicare Fee Schedule and Physical Therapy Reimbursement

All Medicare reimbursement rates are determined by the Medicare fee schedule. The Medicare fee schedule is the comprehensive list of maximum reimbursements that all healthcare providers—not just physical therapists—can expect for the treatment they deliver.

It’s essentially a list of all the different products, services, and procedures you might use in your clinic, identified by a unique Healthcare Common Procedure Coding System (HCPCS) code. The fee schedule gives each one a specific cost, determined by a range of factors, including the complexity of a particular service, the equipment needed, and inflation.

However, it’s important to know that the number listed in the fee schedule is not necessarily the amount you’ll receive for the treatment your clinic delivers. It’s just the maximum.

You may get less, depending on whether an assistant provides the treatment, whether the relevant code is affected by the MPPR, and where you’re located. For example, as metropolitan areas tend to have higher wages than other areas in a state, the reimbursement rates there will be higher.

CPT Codes and Their Relevance

One of the major challenges for physical therapy clinics and their billing teams is navigating the complex systems of billing codes.

If you use the right software to manage your practice , you don’t need to worry too much about these codes yourself. However, they are fundamental to the way Medicare reimbursements are processed. For example, if you do not follow the CCI edits (modifiers) required for the therapy codes you bill, your reimbursement claim is likely to be denied.

There are two main types of billing code, and you’ll find them both in the Medicare fee schedule. Confusingly, the terminology overlaps a little:

• CPT (Current Procedural Terminology) codes. This is the coding system that’s designed to help medics report on procedures and services they deliver. It’s maintained and copyrighted by the American Medical Association (AMA). For physical therapists, this is the most important coding system there is and it’ll be the one you use most often.
• HCPCS (Healthcare Common Procedure Coding System) codes. HCPCS is the general system for all billing codes, managed by the Centers for Medicare and Medicaid Services (CMS). HCPCS is broken down into two “levels”, Level I and Level II:
• HCPCS Level I is the coding system for procedures and services. It’s the same thing as the CPT coding system.
• HCPCS Level II is the coding system for supplies, devices, and equipment. It’s much less commonly used by physical therapists, but it’s still important to know.

Whenever you treat a patient, as a therapist you’ll have to record all the treatment you deliver in your clinical documentation. That’s not just for your own records; when it comes to clinical compliance and reimbursement, your documentation must include codes relevant to the treatment you render.

There is another type of code that you should include in your documentation too: ICD-10 codes. This is the International Classification of Diseases (10th Revision), which is managed by the World Health Organization (WHO) to record diagnoses and classify health statistics.

The only reason you’ll need to worry about this as a PT is because payers like Medicare will want to see that the treatment you deliver is relevant to the diagnosis. In other words, CPT codes need to support ICD-10 codes that are documented. Again, if they don’t, you might not get reimbursed.

Examples of common CPT codes for physical therapists

To give a few examples, here are some of the CPT codes commonly used by physical therapists. Most codes relevant to PT are numbered 97001 to 97799:

• 97010—cold packs.
• 97110—therapeutic exercise.
• 97113—aquatic physical therapy.
• 97116—gait training.
• 97124—massage.
• 97140—manual therapy.
• 97150—group therapy.
• 97161—PT evaluation: low complexity.
• 97162—PT evaluation: moderate complexity.
• 97163—PT evaluation: high complexity.
• 97535—self-care or home management training.
• 97750—functional capacity evaluation.

Latest Medicare Reimbursement News and Updates

CPT and other codes—as well as reimbursement rates themselves—are updated regularly. To ensure that you continue to bill accurately, you’ll need to stay on top of these changes.

For example, at the end of 2022, the AMA released a set of updates that would change how you bill in 2023. These included 393 editorial changes, with 225 new codes, 75 deleted codes and 93 revised codes.

Many of these changes were relevant to evaluation and management (E/M) CPT codes. Other new codes were in the field of AI and virtual technology.

For more information and regular updates, you can check out AMA’s Medicare and Medicaid news.