Ask the Compliance Experts: Live Billing Q&A FAQ

I wasn’t able to answer everyone’s question during our latest billing Q&A webinar, so I’ve addressed all the outstanding ones in this blog. Before we dive in, one disclaimer: The answers provided by our presenters in this FAQ  should not be considered legal advice. They represent the opinions of the presenters based on their knowledge and experience.

Telehealth

We have run into issues with our Medicare telehealth services. Are there any updates on how we should proceed with this? We’ve currently stopped accepting Medicare telehealth patients. 

Most Medicare Administrative Contractors post Telehealth policies on their websites. The American Physical Therapy Association also has resources on its website at apta.gov.  Remember, until Congress acts, Telehealth Services by Rehabilitation professionals are no longer covered in the Medicare program under Part B.

We are an out-of-network provider that provides Video Sessions for Physical Therapy. Does the change as of 9/30/2025 affect commercial payers like BCBS or Emblem Health? 

No, it does not.

Dry Needling

Does Medicare cover dry needling in a PT clinic, or can you exclusively set it up as a cash pay service? If so, what modifier must be submitted? We have a couple of patients who want us to bill Medicare so we can send it to their secondary insurance to possibly pay when Medicare does not. 

We suggest you use an ABN and Bill the services with a GX modifier.

I have a clarifying question about cash pay services like dry needling.  If we are in network with any payer, whether commercial or Medicare, must we submit the service to the insurance provider? And we cannot just collect cash and then not submit a claim? 

You do not have to bill dry needling services to Medicare in order to bill the patient for those services at the time of service. We recommend you use an ABN, and if the patient indicates on the ABN that they want Medicare billed, then bill the services with the GX modifier. If you are in-network with a payer and they deny the services as not medically necessary, you cannot bill the patient for those services. Some in-network agreements require you to bill all services to the pair. Others do not. If your contract with the payer states that you cannot balance-bill the patient for non-medically necessary services, then you cannot bill the patient even if you do not submit claims to the payer.

Group therapy

Group therapy is defined as 2-6 patients. What if I have 10 patients?

In the CPT definition of the group code 91750, there is no maximum number of patients in a group. Individual payers may have rules that you can identify in the appropriate physical therapy or Rehabilitation medical policy on the payer’s website.

What is the Medicare fee for the group therapy code?

Go to your Medicare Administrative Contractor’s website and look for the Fee Schedules link and look for the fee schedule link.

Is there a CMS link that says “Group Therapy has a different definition in an OP setting?”  

The definition of the group code in the outpatient setting, regardless of payer,  is determined by the AMA in the CPT manual.

Home health

Our clinic has seen an increase in HHC agencies extending their billing for a 30-day period, even after the patient has been discharged. We’ve also experienced more denials because HHC later reinstates its billing period after we’ve already begun outpatient treatment. We’ve also appealed to Medicare, but haven’t had any success. What can we do about this? 

Your therapists should ask the patient on every visit whether they are seeing anyone from home health care. You can also call the Home Health Care Agency to verify they aren't seeing the patient. Since patients cannot be covered under Part A and Part B simultaneously, you will not be able to get paid if your patient is covered by a Part A home health care plan of care. 

Can we appeal a Recoupment for Medicare Part B Visits seen? A Home Health Company picked up the same patient without us knowing about it (and the Home Health only picked up for Nursing, not PT/OT or ST). 

No. Since patients cannot be covered under Part A and Part B simultaneously, you will not be able to get paid if your patient is covered by a Part A home health care plan of care. 

ABN

Can we have Aetna patients who have an MRN review after 25 visits sign a statement stating they will be responsible for dates of service that Aetna determines are not medically necessary? And if the patient becomes financially responsible for therapy, can we offer a cash price for their visits that Aetna will not cover because they are not deemed medically necessary? We have found that Aetna may take weeks or months to determine whether they will cover any visits after the 25th visit,  all while the patient is still being seen for treatment. 

If you are an in-network provider for Aetna, your services agreement with Aetna does not permit you to collect payment from the patient for services that are determined to be not medically necessary. 

Is there a gold standard form for an ABN available to practices from Medicare, or is this a form created by practices individually? 

You must use the Medicare ABN form, which is available on your Medicare Administrative Contractor's website.

Is it against the law to have Medicare Advantage and commercial patients sign an ABN?

The ABN is a Medicare document. Unless you customize it for use with another payer, you can not use it with another payer.

Cash Pay/Patient Responsibility

Are PTs and OTs allowed to charge cash to Medicare patients? I have seen an influx of therapists who claim to be cash-based, including those who accept Medicare. 

There is no cash-pay option for Medicare. PTs and O's cannot opt out of the Medicare Part B program by federal law. You do have the option to not participate with Medicare, which allows you to collect at the time of service. See our blog article on Medicare par/non-par for more information. 

Can I charge cash pay for a patient who wants to continue PT when it is no longer medically necessary, even if I am in network with their insurance? Or if they’ve exhausted their benefits limit? 

You'll need to check your preferred provider agreement to see if it allows you to see a patient for services that are not billed to the insurance company. With Medicare, you can do this by using the ABN form process.

Does allowing a patient to switch from using their private insurance to being a cash pay patient violate contracts with insurance companies, or does the patient have the right to switch?  

If you are in network with a payer, you will likely be required to bill all services to the payer for that patient. You should check your contract or service agreement to verify.

Do our cash pay rates need to be at or above Medicare allowed amounts if we are contracted with Medicare? Is there a fee schedule where we can locate these amounts? 

Your Medicare fee schedule can be found on the website of your Medicare Administrative Contractor. For services that qualify for cash payment by Medicare patients, you may make whatever financial arrangements you wish with the patient.

We were referred a Medicare patient who does not have Part B. We billed Medicare, and all his visits were denied.  Unfortunately, we did not realize that he only had part A until after he was treated.  The patient is insisting on paying out of pocket for his visits. Can we collect from him? 

Yes, the patient does not qualify for Part B services.

What if the patient had insurance, but then switched to Medicaid the next month, and the clinic was not aware? Can you bill the patient when they are on Medicaid? The clinic would be out of network with certain Medicaid plans. 

Medicaid rules on the share of cost vary from state to state and even within States, depending on which program in the state's Medicaid Program the patient has coverage. You should be able to determine that by looking at their Medicaid card and then checking the Medicaid website for your state or the particular program they're covered under.

Authorizations

If Prior Authorization is stated as not needed during insurance verification but is then denied at claim submission because it is actually needed, can you balance bill the patient? 

You should first try to get retroactive authorization on the basis that you were given inaccurate information when you called to verify benefits. If the payer will not do that, then you should rely on the EOB/ERA to identify if the balance was assigned as a contractual write-off or assigned to the patient.

For BCBS HMO, can we make it the patient's responsibility to obtain a referral from their PCP and have the PCP handle the authorization through BCBS? And then once they have it, they can send it to us, and then we can schedule them? 

Yes, that’s correct.

Denials/Services Not Covered

Any ICD-10 code with a POA (present on admission) designation is being denied, even though it was previously acceptable. Do you have any advice? 

You should follow up with the payer to understand what your limitations are relative to POA diagnoses. 

We are getting denials when we have multiple disciplines treating on the same day. We then have to resubmit with the XP modifier. Is there a way to do this proactively?

First, ensure you are billing with the correct GP, GN, and GO discipline modifiers. You should also consider using the 76 and 77 modifiers to distinguish different therapists using the same CPT codes for their parts of the treatment.

We have always been denied payment for services beyond the therapy threshold; are there any tricks to getting paid? 

You need to apply the KX modifier to all services once you reach the KX threshold. 

If you receive a CO 22 denial and the patient does not respond to multiple attempts to get updated insurance info, is there anything you can do? You can't bill a patient with a CO denial, correct? 

You should have a financial policy that states that the patient is ultimately responsible for their bill if the insurance company does not process the claim correctly. This would also include their failure to cooperate with requests for information.

We are having a hard time getting paid for grafting for ulcers on feet, i.e. the Q4133 codes, especially with UHC Advantage plans.  What should we be doing? 

You need to consult the payer's website to see what their treatment rules are around biological substitutes for skin grafts. 

Aetna does not allow more than one evaluation every 180 days.  We have tried appealing cases where there are two very distinct body parts or conditions, and they are denied.  For commercial plans, we can have the patient sign a waiver stating that they will be responsible for the evaluation code; however, we are not allowed to do so for Aetna MA plans.  Do you have any advice on how to handle these situations? 

While it is a bad payment policy, Aetna requires you to bill for a reevaluation for any new conditions during the 180 days after an initial evaluation.

We provide every patient with EStim, but no insurance covers this. Is there any way to get compensation for this, or is it just a write-off? 

If you are in network with the payer, you will need to follow the guidance on the EOB/E RA as the balance will be assigned to the patient or to the practice as a contractual adjustment. If you are out of network with the payer, you may collect the fee for the electrical stimulation as long as you did not accept assignment for that treatment. 

Credentialing

Are there any other fill-in options for clinics that do not meet the criteria for locum tenens, i.e., not in a medically underserved area or health professions shortage area, or in a non-metropolitan statistical area?  

Unfortunately, no.

Can you bill Medicare for a provider who is currently being credentialed?  It is our understanding that we must hold the claims until they are credentialed, and that we should wait until Medicare has officially accepted the application for review before the provider can do even that.  

The therapist may start seeing Medicare patients effective the date of their completion of assignment on the 8:55i. Those claims should then be held until you receive written notification for Medicare of their acceptance as a credential provider. 

Can I, the owner, hire a 1099 independent contractor that only sees patients at a self-pay rate while other PTs are credentialed with insurance payers? 

That depends on the payer and your contract with the payer. if your credentialing is on the tax identification number level, then you cannot. If it is on an individual NPI number basis, then you can. 

Modifiers

I’m billing BCBS ND for codes 97140 and 97012, using the 59 mod on 97140.  They are only paying out the allowable amount on 97012, which is $12. What is the proper way to code these to get payment for both? 

You are placing the 59 modifier on the correct CPT code. You should look at the EOB to understand the specific reason for denying the claim. There should be a remark code there that provides guidance. Remember, commercial payers do not always follow the current CCI coding edits. You have very little recourse when that happens.

How should you bill if a patient has two different doctors sending them for different body parts? Should they have two cases, and should you use an XE modifier for coverage? 

Most software will require you to set up two different cases for the situation. You can use the XE modifier in this case, or you could consider using the 76/77 modifiers to distinguish different therapists providing the same service on the same day. 

Medicare Advantage

Can you speak to opting out of MA plans?  I was informed that it's difficult for large payers, such as UHC, since they also offer commercial plans, but what about a plan like Devoted Medicare? 

Some payers will not allow you to opt out of Medicare Advantage coverage when you want to remain contracted with their commercial business. You will need to make that decision on a case-by-case basis.

Does the Medicare Advantage self-pay rate need to be the same as the Medicare fee schedule if we are out of network with the plan? 

It does not have to be the same rate as Medicare Part B. However, you cannot exceed the global limiting amount of the Medicare Part B fee schedule. You can look this up on the fee schedule page for your Medicare Administrative Contractor.

Do Medicare Advantage plans and commercial insurance plans have to cover maintenance therapy? 

No, they do not.

Fee Schedule

Can a PT practice charge a separate cash fee for the onboarding of our patient exercise software/ HEP platform?  

No, not if you are in network with a payer. 

We’re seeing a patient who has Aetna Medicare Advantage as an out-of-network provider with Aetna, but participating with Medicare. The Aetna plan doesn't follow the Medicare fee schedule.  Is that permitted?  Shouldn't the allowed amount be the same as the Medicare fee schedule?  

Medicare Advantage is covered under the Medicare Part C program. As a result, the payer is not required to adhere to the Medicare Part B fee schedule. They can determine their own contract amounts, which you choose to accept when you contract with them.

Can you please review the appropriate charge master fees? Is the rule of thumb to add 50% to Medicare’s fees for each CPT code? 

Typically, practices charge anywhere from 25% to 50% over the Medicare allowable to establish their fee schedules.

Can you clarify whether we are required to bill insurance, even if we are in-network, and even if the patient doesn't want us to, in order to save money? 

Be sure your patient understands that they will not get credit towards their deductible if they choose to do this. If you are in-network with a payer, your agreement likely prohibits you from doing this with the patient covered by that payer.

Education

When researching payer-specific rules (such as signed POC requirements), what are the best resources? 

The medical policies or reimbursement guidelines for PT, OT, or outpatient rehabilitation on the payer website.

What's the best resource for PTs to read up on for billing mistakes? For example, if we want to know about diagnosis code inconsistencies or have continued awareness of changes. 

You should sign up for the monthly newsletters and Communications from any payers with whom you are in network. Another way to keep current is to be sure that you get a CPT manual for the current year, an ICD-10 manual for the current year, as well as a separately published ICD-10 guidelines. The ICD-10 codes and guidelines are available for free online.

Hospital   

Can you speak to hospital billing for observation patients?  Do the therapists’ charges follow the outpatient rules or the inpatient rehab rules?  

The charges should follow the Outpatient Part B rules.

Billing

For Speech Therapy, what are the ICD-10 Codes that can be billed for Age-Related Cognitive decline? Humana started denying ICD-10 Code R41.81; what is the alternative code for this diagnosis? 

You must rely on the Related Medical policies published on the payers’ websites.

Must the provider be in the pool when billing 1-1 for aquatic therapy 9711 when treating the patient? 

The therapist must either be in the water or on the deck but still one-on-one with the patient.

We are seeing an MVA patient and her PIP has run out.  We have always waited on a lien, as we do not bill the commercial insurance as it was an MVA, which we learned over time.  We have clarified this with the insurance company.  The attorney is saying we have to bill the commercial insurance.  Who is correct? 

The medical insurance either will not pay or will pay and require the patient to sign a subrogation agreement.

Our Medicare patient is being treated for one diagnosis.  In the middle of this treatment, they come in with a new prescription for a different diagnosis. How to go about treating? Can a second diagnosis be just added? Do we need a new eval and cancel treatment for the previous? 

Do a new evaluation on the second problem. Then, do a plan of care for the second problem or rewrite both problems into one plan of care. Remember, payers do not recognize the concept of a “visit” as they consider all services rendered within a calendar day to be one date of service. 

If an occupational therapist only formulates a home exercise program and instructs the patient on the program, can this work be reimbursed? 

Yes. as long as the correct movement intervention codes are billed for the service.

If an employee abruptly quits and leaves several notes unsigned, what are our options for submitting those services for payment? 

We suggest you contact the payer and ask how they would like that handled.

Do any commercial payers limit the number of patients a therapist can treat in one hour, with the exception of Medicare?  

There are 60 minutes in an hour, so the number of services you can bill would depend on the one-on-one time of the codes, and if you billed any one-time services. Some payers limit the number of services that can be billed on a single date of service for a patient. You can determine this by reading the medical policy governing physical or occupational therapy on the payer's website.

Can you review NDT versus neuromuscular billing? 

If you provide neurodevelopmental treatment services, you would bill it as neuromuscular rehabilitation CPT code 97112, in 15-minute increments. 

We have a provider group that thinks that they don't need to document time for time-based codes for non-Medicare payers. We have pointed out that it is a CPT requirement, and without the time documented, the code would not be supported, and they still will not comply. Any ideas on how to get them to buy into documenting time? 

That sounds like a personnel problem. Have you consulted your human resources department?