Navigating the Challenges of Physical Therapy Billing and Coding

Physical therapy offers significant benefits for individuals of all ages dealing with medical conditions, injuries, or chronic diseases that hamper movement and function. These services help patients maintain optimal physical health and mobility. However, billing for physical therapy services can be challenging, with providers often encountering claim denials due to issues such as eligibility concerns, changes in reimbursement schedules, difficulties in establishing medical necessity, telehealth considerations, and improper use of codes and modifiers. Given these challenges, outsourcing physical therapy medical billing and coding to an expert is a practical strategy to ensure accurate claim submission to Medicare and private insurance. Experts can assist providers in utilizing the most precise physical therapy CPT codes to accurately reflect the services provided, ensuring correct billing for both timed and untimed therapy CPT codes, among other important tasks.

H2 Understanding CPT Codes for Physical Therapy

CPT codes are essential tools in the billing process for physical therapy services. Reporting the correct CPT codes are crucial for ensuring accurate billing, appropriate reimbursement, and compliance with insurance requirements.

In physical therapy, these codes cover a range of treatments, including evaluation, therapeutic exercises, manual therapy, and other modalities. Medical coders can help physical therapists to use the appropriate codes to communicate effectively with insurance companies and other payers about the care provided.

Here are the common CPT Codes used in physical therapy

CPT codes for PT Evaluations and Re-evaluations: CPT code descriptors for physical therapy evaluations outline the specific components needed for accurate reporting, along with the typical face-to-face duration for each service. These evaluation CPT codes are categorized based on the complexity level of the therapy evaluation performed, which can be classified as low, moderate, or high complexity.

97161: Physical therapy evaluation, low complexity

97162: Physical therapy evaluation, moderate complexity

97163: Physical therapy evaluation, high complexity

To report the level of PT evaluation, the documentation must include the History, Examination, Clinical decision-making and Development of care plan components.

97164 PT re-evaluation: The American Medical Association (AMA) specifies that 97164 denotes a re-evaluation of an established plan of care, which requires these 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

CPT codes 97164 should be reported 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.

According to Medicare guidelines, a re-evaluation is medically necessary (and 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 plan of care (POC).

CPT Codes for Common Physical Therapy Interventions

97110 Therapeutic Exercise

97140 Manual Therapy

97530 Therapeutic Activities

97010 Hot/Cold Packs

97014 Electrical Stimulation (Unattended)

G0283 Electrical Stimulation, Medicare Non-Wound (Unattended)

97035 Ultrasound/Phonophoresis

97116 Gait Training

97032 Electrical Stimulation (Manual)

97012 Mechanical Traction

97150 Group Therapy

97124 Massage Therapy

98941 Spinal, Three or Four Regions

97039 Laser/Other

97026 Infrared Light

H2 Billing Timed versus Untimed Physical Therapy Services

The key difference between timed and untimed CPT codes in physical therapy is that timed codes are billed according to the duration of the service provided to the patient, while untimed codes are billed based on the specific service rendered, regardless of the time spent.:

Timed codes are typically used in 15-minute increments. For example, CPT 97112 - Neuromuscular Re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (one or more areas, each 15 minutes).

CPT codes 97032, 97033, 97035, and 97110 are also timed codes. Adhering to Medicare’s 8 Minute Rule is a critical guideline for proper billing and reimbursement process for timed physical therapy services.

Untimed codes are service-based CPT codes that are billed once per session, regardless of how long the treatment takes. Examples of service-based physical therapy codes:

● 97161, 97162, or 97163 - physical therapy evaluation

● 97164 - physical therapy re-evaluation

● 97010 - hot/cold packs

● 97014 or G0283 for Medicare - electrical stimulation (unattended)

H2 Key Physical Therapy Billing Challenges

Accurate CPT coding is critical for physical therapists to ensure that the services provided are correctly billed and reimbursed. Errors in coding can lead to claim denials, delays in payment, or underpayment for services. However, billing for physical therapy services is challenging.

One of the challenges in physical therapy billing is the potential for CPT codes to be bundled or rejected by insurers. When an insurance company groups multiple services under a single code it results in bundling, which can reduce the amount reimbursed. Understanding how to use modifiers with CPT codes can help prevent bundling and ensure that appropriate reimbursement is received for services rendered.

Another billing challenge is missing information: Incomplete patient details, lack of prior authorizations, or insufficient documentation of medical necessity can lead to claim denials.

Denials can also occur if services are provided to patients who are not eligible at the time of the therapy session. To avoid this, practices need to have a reliable insurance eligibility verification process in place.

In addition to using the correct CPT codes and modifiers, physical therapists must accurately assign the most specific ICD-10 codes to reflect patient diagnoses. To prevent claim denials, it’s essential that all codes correspond with the services rendered. The complexities of coding—including adherence to time requirements, navigating varying payer regulations by state, managing insurance verification, and keeping up with evolving codes—make physical therapy billing quite challenging. In these situations, partnering with a medical billing company that specializes in this field can be a practical solution. An expert can ensure accurate billing and coding while maintaining compliance with insurance requirements, allowing physical therapists to receive proper reimbursement for the care they deliver.