Physical therapy benefits people of all ages who have medical conditions, injuries, or chronic diseases that limit movement and function. Physical therapy services help them maintain an optimal level of physical health and mobility. The demand for occupational and physical therapy rehabilitation services in the U.S. is growing, according to a recent Fortune Business Insights market research report. However, physical therapists face high claim denials due to eligibility issues, changes schedules relating to reimbursements, failure to establish medical necessity, telehealth considerations, and misuse of codes and modifiers. With all of these challenges, outsourced physical therapy medical billing and coding services are a practical option for providers to manage claim submission to Medicare and private insurance. An expert can help providers use the most specific physical therapy CPT codes that appropriately describe services rendered, bill units of timed and untimed therapy CPT codes correctly, and more.
Correct coding begins with knowing the CPT codes used in physical therapy.
Common CPT Codes in Physical Therapy
Procedural or CPT coding for physical therapy comprises of codes for evaluations, re-evaluations, and treatment.
CPT codes for PT Evaluations and Re-evaluations: CPT code descriptors for physical therapy evaluations include specific components required for reporting, as well as the corresponding typical face-to-face times for each service.
The evaluation CPT codes are assigned on the basis of whether a low-, moderate-, or high-complexity level therapy evaluation was performed:
97161: Physical therapy evaluation, low complexity
97162: Physical therapy evaluation, moderate complexity
97163: Physical therapy evaluation, high complexity
To report the selected level of PT evaluation, the documentation must include the History, Examination, Clinical decision-making and Development of care plan components.
97164 PT re-evaluation: AMA’s CPT descriptions and guidelines for re-evaluation of physical therapy established plan of care (97164), requires completing and documenting the following components:
- An examination including a review of history and use of standardized tests and measures is required; and
- Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome
Use 97164 if a patient does not respond as anticipated to the treatment summarized in the current plan of care, and a change to the plan is necessary.
Under Medicare guidelines, a re-evaluation is medically necessary (and therefore payable) only if the therapist determines that the patient has had a significant improvement, or decline, or other change in his or her condition or functional status that was not anticipated in the POC.
Common CPT Codes for Physical Therapy Interventions
Common CPT codes to report physical therapy services:
97110 Therapeutic Exercise
97140 Manual Therapy
97112 Neuromuscular Re-Education
97530 Therapeutic Activities
97010 Hot/Cold Packs
97014 Electrical Stimulation (Unattended)
G0283 Electrical Stimulation, Medicare Non-Wound (Unattended)
97116 Gait Training
97535 Self Care/Home Management Training
97016 Vasopneumatic Device
97032 Electrical Stimulation (Manual)
97012 Mechanical Traction
97113 Aquatic Exercise
97150 Group Therapy
97124 Massage Therapy
97018 Paraffin Bath
98941 Spinal, Three or Four Regions
97026 Infrared Light
97750 FCE/Physical Performance Test
Insurance companies reimburse therapists for these codes based on the resource-based relative value scale, which means that payment depends on the work the therapist performs, the expense to the practice, and the liability and risk in providing the services.
Time-based Physical Therapy Procedure Codes vs. Untimed Procedure Codes
There are two different types of billing codes to bill Medicare for physical therapy services: untimed and timed codes.
Timed codes are reimbursed based on the time spent working 1:1 with their patient. Physical therapy time-based treatment procedure codes represent 15 minutes of treatment. In order to bill one unit of time for a code, the provider must spend at least 8 minutes performing the service. Timed codes should only be used for skilled interventions and can be billed multiple times per session. 97032 (Electrical Stimulation (Manual); 97033 – Iontophoresis, 97035 – Ultrasound, and 97110 – Therapeutic Exercise are examples of timed codes.
Untimed codes are billed once per session regardless of the number of anatomical body areas treated. When using untimed codes, the PT is paid a predetermined fee, no matter the time spent on treatment. Examples of untimed codes include unattended electrical stimulation (97014) or physical therapy evaluation (97161, 97162, 97163 or 97164).
Physical therapy procedure coding requires the proper use of modifiers:
Modifier 59 – Modifier 59 is used to identify any procedures or services that are not usually performed together, but were appropriate under the given circumstances. However, the National Correct Coding Initiative has identified certain “edit pairs” or physical therapy services that providers commonly perform together. The provider will be reimbursed for only one of these codes. Before using Modifier 59, physical therapists must determine if they are providing linked services or wholly separate services.
Modifier XE, XP, XS, and XU – These modifiers are used to bypass an edit pair, by claiming a distinct encounter, anatomical structure, or practitioner, or simply an unusual service.
Modifier GP indicates that physical therapy services were provided. Modifier GP is required for accurate reimbursement in accordance with plan’s benefits.
Modifier KX is used to indicate that a patient has reached their physical therapy maximum for the year. When using modifier KX, the physical therapist must document medical necessity for the continuation of care. Medicare will pay only if visits after the cap are proven medical necessary.
Physical therapists and physical therapist assistants provide and are reimbursed for a wide variety of services via telehealth platforms. According to the APTA, CMS has added a number of codes to the ‘category 3’ list of codes for which physical therapists can be paid when delivered via telehealth through 2023. As with all other category 3 codes, physical therapists’ ability to bill these codes in association with telehealth will cease 151 days after the PHE ends or until midnight on December 31, 2023—whichever comes first. None of this is effective until January 1, 2023, once the final rule is published (webpt.com).
Outsource Physical Therapy Medical Billing
In addition to using the correct CPT codes and modifiers, physical therapists must assign the most specific ICD-10 code to describe diagnoses. To prevent denials, all codes must match services rendered. With multiple codes and time requirements, payer rules which can differ by state, prior authorization requirements, and changing codes, physical therapy medical billing can be complex. In this scenario, medical coding outsourcing to an expert is the best way to ensure accurate claim submission and optimal reimbursement.
Outsource Strategies International (OSI) provides comprehensive revenue cycle management that includes medical billing and coding solutions, insurance verifications and authorizations, AR management. By outsourcing medical billing to us, providers can prevent denials, maximize cash flow and maintain compliance.