Billing blunders are enough to send chills down anyone’s spine—but a little expertise goes a long way when you’re facing scary billing scenarios head-on. That’s why our experts—Dr. Heidi Jannenga, PT, DPT, ATC, WebPT Chief Clinical Officer and Co-Founder, and John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management—joined forces to host an hour-long billing open forum to help rehab therapists conquer their greatest billing nightmares.
Can’t find the answer to your bump-in-the-night billing quandary? Feel free to drop your question in the comment section below, and we’ll do our best to help you out.
Why do I keep getting denials when billing the e-visit code G2063 with modifier CR?
The CR modifier is not required when billing e-visit codes. Check out this telehealth billing article for more information.
How do we avoid rejections for billing evaluations with CPT code 97140? We’re using modifier 59—what’s going on?
Many therapists have struggled with this problem since CMS updated its NCCI edits for these codes. Continue billing evaluations and 97140 with modifier 59, and make sure that your documentation properly defends your billing. If payers continue to deny these claims, our experts recommend submitting appeals.
A Medicare replacement insurance keeps making the same billing errors over and over again. We’ve spoken with our provider rep to try to resolve the problem—but it keeps happening. What else can we do to resolve the problem? What if it is a workers’ comp plan?
One “last-resort” option is to file a complaint with your state’s insurance commissioner. This process will look different for each state and will require a bit of research on your end. As an example, here’s a page detailing how the complaint process works in the state of California.
What is the correct way to resubmit claims after denials?
If it’s a technical denial (e.g., you forgot to affix the KX modifier when you should have), you can typically fix the claim and resubmit it. That said, many payers have their own appeals policies with specific requirements—using a certain appeals form, for example. To verify the payer’s policy, you should go to the appeals page on the payer’s website. There, you should learn everything you need to know about submitting appeals to that particular entity.
Now, if it’s a policy denial (e.g., the payer does not consider the services medical necessity), then you’ll want to write a letter to the payer that:
- explains why you’re appealing, and
- points to where you believe your documentation justifies the payment.
Our Medicare intermediary, WPS, has decided not to pay for services provided by PTAs, even if they are wound care certified or have approval through their state practice act. Why did this happen—and how do we fight it?
You may not be the only one experiencing this problem. According to this APTA memo, the APTA sent a letter to WPS in January 2020 “to correct misconceptions held by the Wisconsin Physicians Service Insurance Corporation (WPS). This stemmed from correspondence during medical review between WPS and an APTA member, leading the PT member to believe that WPS has taken the position that physical therapist assistants may not perform wound care services.” At this point, your best bet is to reach out to your local chapter of the APTA for further guidance.
Colorado Medicaid has started denying claims where we bill CPT codes 92606 and 92507 together. We can’t find documentation that explains these sudden denials. What’s going on?
Any time you are unable to find documentation or communication that would explain a denial, we recommend reaching out to the payer directly. Here’s the provider contact page for Colorado’s state Medicaid program. If you’re unable to reach someone, you could try reaching out to the Colorado Speech-Language-Hearing Association.
Why am I getting claim rejections from multiple payers that state “invalid diagnosis code used as a principal diagnosis?”
This is an ICD-10 coding issue. It occurs when you bill using primary diagnosis while also including a less-specific secondary diagnosis—particularly when the payer expects that secondary diagnosis as part of the primary one. For example, with a hip replacement patient, you wouldn’t also code for muscle weakness and abnormal gait—because those problems are “given” considering the primary reason you are treating the patient.
How can we avoid rejections due to billing S and Z ICD-10 diagnosis codes? When it comes to getting authorization for post-surgery visits, these codes are required in order to receive the most visits—yet insurance denies as “mismatched” or “principal code not valid” when billed with pain codes or arthritis codes.
As Wallace explained during the webinar, the problem could be the presence of less specific diagnosis codes. For example, if your patient is receiving post-operative care for an artificial joint, stick with the appropriate—and most specific—post-op codes rather than coding for the pain pathology.
DME, Orthotics, and Prosthetics
Can a physical therapist bill CPT codes 97760, 97761, and 97763 without a DMEPOS number?
Under Medicare Part B, a physical therapist must obtain a DMEPOS provider number in order to bill any orthosis codes. For non-Medicare payers, you’ll need to verify this with the payer directly.
How do we bill for L-codes? Which ones are payable?
We actually wrote an entire blog post that explains L-codes (and how to bill for ’em), which you can read here.
Can I bill dry needling as manual therapy or neuromuscular education? I’ve spoken with therapists who have said that they’ve been instructed by experts to bill dry needling as manual therapy. We’ve even lost patients to competitors who have said they can get Medicare to cover dry needling.
No. The AMA specifically approved two dry needling codes: 20560 and 20561. You must use those codes to bill for needle insertion—you cannot hide your dry needling inside another service. Doing so would be considered fraudulent.
Remember that Medicare does not pay for dry needling. It’s considered a noncovered service, which means you can charge the patient cash for dry needling at the time of service. During the webinar, Wallace said he’s heard of providers charging anywhere between $5 and $20 for a dry needling session. Because dry needling is noncovered, you can provide an ABN to Medicare beneficiaries as a courtesy—but it is optional to do so.
Wallace also says that roughly half of commercial payers do not cover dry needling services—but you cannot always bill patients for noncovered dry needling. It depends on how the payer views dry needling. If you’re a preferred provider with a payer, you may be required to bill dry needling and receive a denial that simply states the service is “noncovered”—at which point you can ask the patient to pay out-of-pocket for the service. However, if you receive a denial that says the service was “not medically necessary,” “experimental,” or “investigational,” then you cannot ask the patient to pay out-of-pocket under any circumstance. You also cannot offer free dry needling services, as this violates the federal Anti-Kickback Statute.
What about acupuncture? Can I bill for that?
Acupuncture is recognized as a medically different service than dry needling—and sometimes Medicare even covers it. However, to deliver acupuncture in most states, you must be licensed as an acupuncturist or a Traditional Chinese Medicine practitioner.
We have been billing CPT codes 20560 and 20561 for dry needling. We want payers to deny the code and leave the balance to the patient, but most payers deny the code (stating it’s investigational or not covered), and leave no balance responsibility for the patient. How can we fix that?
Unfortunately, dry needling denials are up to payer discretion. If a payer denies these codes and lists the denial as “noncovered,” then you can ask the patient to pay out-of-pocket for the service. However, if the payer denies the service because it was “not medically necessary,” “experimental,” or “investigational,” then you cannot legally ask the patient to pay out-of-pocket—nor can you provide free dry needling services.
Should patients who do not have dry needling coverage sign an ABN? Should we take payment up front?
First off, only Medicare beneficiaries sign ABNs, and you only need to issue one if you expect that Medicare will not pay for a usually-covered service that you’re about to provide the patient. Because dry needling is never covered by Medicare (meaning the patient can never expect Medicare to pay for it), you don’t technically have to issue an ABN to the patient—although you can do so as a courtesy. Either way, you can collect payment for the service up front—and it’s probably wise to do so.
How do you bill group therapy? What treatments can and cannot be billed under group therapy? Do I need to use any modifiers?
For an in-depth overview of how to bill for group therapy services—and how to determine when it is appropriate to do so—check out this article from the WebPT Blog.
When billing for overlapping patients on the schedule (one Medicare and one commercial insurance), can you bill group therapy (97150) to the Medicare patient for the time that is spent bouncing back and forth between patients?
First, it’s important to know that the description for each CPT code designates whether or not it is strictly a one-on-one service. If you’re providing group therapy, then by definition, it doesn’t matter which insurance each patient in the group has. You can jump back and forth between a Medicare beneficiary and a commercial patient—no problem. However, you cannot bill a one-on-one code and group therapy for the same segment of time. To learn more about the ins and outs of billing for one-on-one services versus group therapy—including how to bill for one-on-one services while treating multiple patients—check out this blog post.
Can you discuss how acute care therapists can be educated on how to bill like an outpatient therapist for patients who are considered “observation” or “outpatient in a bed” status? Often, we have patients in the hospital for 24–72 hours, but they are considered outpatient or observation.
Our Complete Guide to Physical Therapy Billing—which you can download free of charge here—provides a comprehensive explanation of the ins and outs of outpatient physical therapy billing. This is a great introductory educational tool for any therapist who is unfamiliar with outpatient billing requirements.
With respect to 99072, it’s my understanding that this new code is only applicable for visits submitted to an insurance carrier on a 1500 claim form and would not be appropriate to bill on a UB-04 claim form. Is that correct?
Yup, that’s correct. As compliance guru Rick Gawenda explains here, CPT code 99072 is intended for non-facility services, meaning it should not be used for services occurring in a hospital setting and thus, would not be appropriate to bill on a UB-04 form.
Our hospital is trying to improve early mobility in the ICU, and I am concerned because the therapy department has been asked to perform what appear to be non-skilled services. How can we improve patient care and still bill for our services?
Unfortunately, you cannot bill for unskilled services. These services and procedures are typically relegated to techs or aides for that very reason. If your team has any extenders on staff, you could improve patient care by having techs perform the unskilled activities.
Also, depending on the service, it might be worth checking to see if they are billable in some way. For instance, some services can be included in the time you spent providing the related service (e.g., patient education, hot/cold pack, etc.).
How can therapists who work in a HOD PT department bill (and be paid) for services provided in an ambulatory physician office—without incident-to billing? What compliance standards do we need to meet?
According to Wallace, this depends on who is supposed to get paid: the physician or the HOD PT. If it’s the hospital, check in with the hospital’s compliance officer regarding standards and requirements.
Is it possible for a pro bono clinic to provide skilled services to a Medicare beneficiary?
From what we understand, no. Medicare does not allow providers to waive copays or deductibles—and because therapists can’t completely opt out of Medicare, they’re unable to provide covered services to Medicare beneficiaries on a cash-pay basis. Technically, therapists can provide noncovered (e.g., wellness) services to beneficiaries on a cash-pay basis, so you may be able to offer those services pro bono. That said, we recommend reaching out to a healthcare attorney to ensure you cover your bases.
I am a Medicare non-participant. Where can I find the amount I can charge per code and unit? I see that CMS states I can bill up to 15% above the Medicare RVU—or a reasonable charge. How does that work?
As explained in this Medicare billing resource, “If assignment is not accepted, the patient will pay out of pocket for the service. In this case, the most the provider is permitted to charge the patient is 115% of the allowable fee. This is known as the limiting charge.” To determine the allowable fee for individual CPT codes, use this Medicare Physician Fee Schedule (MPFS) look-up tool.
If we choose to leave Medicare next year, can we see Medicare patients who want to pay cash?
No. Unlike other healthcare providers, PTs are unable to completely opt out of Medicare and treat Medicare beneficiaries on a cash-pay basis. As such, PTs who want to serve Medicare patients must, at the very least, accept Medicare assignment. (Learn more here.) That said, you may offer Medicare patients cash-pay services that are never covered by Medicare (e.g., wellness services and dry needling).
Because CMS does not recognize 97010 (hot/cold packs) in its fee schedule and does not consider it a skilled service, should providers bundle it in with other services?
As explained in this article from ACA Today, “Medicare considers CPT Code 97010, Hot/Cold packs…‘bundled’ services. This means that it’s not a separately billable service. It will be considered a part of whatever primary service is rendered to the patient on that visit.”
Will the 9% cut affect Part B therapy services billed by critical access hospitals (CAHs)?
To our knowledge, yes. CMS is implementing the 9% cuts by cutting the conversion factor, which applies to all codes on the Medicare physician fee schedule.
Will automatically be audited if I exceed Medicare’s $3,000 therapy threshold?
No, you will not automatically be audited once you exceed the $3,000 threshold. To learn more about exceeding the KX modifier thresholds, check out this blog post.
What are Medicare’s plan of care (POC) and physician signature rules?
When creating a plan of care for a Medicare patient, it must include the following:
- “Medical diagnosis
- Long-term functional goals
- Type of services or interventions
- Quantity of services or interventions (number of times per day the therapist provides treatment; if the therapist does not specify a quantity, Medicare will assume one treatment session per day)
- Frequency of treatment (number of times per week; do not use ranges)
- Duration of treatment (length of treatment; do not include ranges)”
Once you’ve created the plan, you must have a physician sign and date the POC within 30 days of the patient’s first treatment. The POC will expire after 90 days, so if you plan to continue seeing the patient for longer than that, be sure to recertify the plan (i.e., get a new physician signature) before the POC expires.
Modifiers and NCCI Edit Pairs
When can PTs use modifier 25?
We covered this topic in depth in this WebPT Blog post.
Do we need to bill 99072 with any modifiers?
We’re not sure, yet. As of early October 2020, CMS had yet to make a decision about whether or not 99072 required any modifiers.
Some insurances deny all or part of a claim because of NCCI edit pairings. Does this change if we use the XU modifier instead of the 59 modifier?
No. Not all payers require X modifiers—and even if they do, using one doesn’t guarantee that you will be paid in instances where you’ve received denials when using modifier 59. As for Medicare, CMS has specifically designated 59 as the appropriate modifier for claims involving NCCI edit pairs.
What kind of documentation is necessary to support use of the KX modifier when continued treatment is medically necessary?
Establishing medical necessity requires having a plan of care signed by the therapist and physician. That POC should include goals that are achievable, and you should continually document the patient’s progress toward them. The key is showing how your skilled therapy is allowing the patient to progress toward the goals outlined in the POC. Additionally, make sure you’re completing progress notes at the required intervals. For more advice on documenting for medical necessity, refer to this blog post.
If I bill codes 97140 and 97530 and append the 59 modifier, will both codes get paid—or just one? Does my documentation need to prove that both codes should be paid?
When you append the 59 modifier to your claim, you’re signalling to the payer that “you provided both services in the pair separately and independently of one another—meaning that you also should receive separate payment for each procedure.” And yes—your documentation should always be defensible. It needs to prove the medical necessity of every service you furnish—including the services that require modifier 59.
With the current NCCI edits in place, which codes cannot be billed in conjunction with an evaluation?
The follow CPT codes cannot be billed alongside PT evaluation codes 97161–97163:
The follow CPT codes cannot be billed alongside OT evaluation codes 97165–97167:
What’s the best practice for billing both 97110 and 97530 for a same-day therapy session?
These codes do not form NCCI edit pairs, so simply perform the services, accurately code for the time spent delivering them, and ensure your documentation justifies your code selection as well as the medical necessity of each service.
How do I find out which insurances won’t pay for 97140 with an evaluation or CPT code 97530?
Contact the insurance and verify whether it adheres to Medicare’s NCCI edits policy. If it does, bill appropriately using modifier 59. Keep in mind that some payers may prefer or require use of an X modifier in place of modifier 59, so be sure to verify that as well. Finally, note that, as Wallace mentioned during the webinar, many commercial payers are incorrectly issuing denials for certain edit pairs even when modifier 59 was used appropriately. In such cases, you should absolutely appeal the denial. You can learn more about that process here.
Multiple Treatments—Same Patient
How can we successfully bill for multiple therapists from multiple disciplines providing therapy to the same patient on the same day? Even when we submit separate claims, we’re still getting rejections for duplicate services.
In outpatient settings, payers tend to lump together all services provided to a patient on one date of service—regardless of discipline. So, if a patient receives physical, occupational, and speech therapy on the same day, you’ll need to use the appropriate therapy modifier (e.g., GP, GO, or GN) to differentiate the services.
But, even if you do everything correctly, Wallace says many commercial payers still do not pay these claims correctly. In these cases, you’ll have to appeal the denials and explain that the services were delivered by different therapists. To learn more about submitting appeals, check out this blog post and this one.
When performing treatment bilaterally, do you have to always complete two evaluations (one per side) and two separate notes (one per side)?
You can combine documentation, but you absolutely must be clear about what you’re doing on each side. In many cases, you won’t be rendering the same treatment to both sides. But even if the treatment is the same on both sides, be sure to pick the ICD-10 code that indicates bilaterality. If you’re using a code that doesn’t account for laterality, you can affix the LT and RT modifier to the corresponding CPT codes to indicate that the services were performed on both sides.
How should you bill for a patient being treated for multiple diagnosis (e.g., left knee pain and right shoulder repair) if the referring physician is not the same? The claim form only allows for one referring physician.
First off, if this is a Medicare patient, be sure to have both physicians sign off on a plan of care that incorporates both diagnoses. Otherwise, you’ll have to maintain two separate plans of care. Then, document for each diagnosis separately. Keep in mind that even when you’re documenting separately, you have to correctly match each ICD-10 code to the corresponding CPT code to indicate what was done to each body part. In other words, you cannot apply all of the ICD-10 codes to all of the CPT codes.
How do you bill for treatment performed on multiple body parts or for multiple diagnoses on the same day?
With respect to Medicare (be sure to verify for each commercial insurance), as we explain here, “When treating a patient for two separate diagnoses on the same day, you’ll need to combine these services onto one claim. Furthermore, if more than one therapist is treating the patient on this date of service, both therapists’ treatments would have to be on the same claim. For additional information on co-treatment under Medicare, check out this blog post. Now, if you’re billing for two services that Medicare would normally consider linked or bundled—but you provided them for the treatment of separate injuries and/or body parts, thus warranting separate payment—then you would affix modifier 59 to the appropriate code, as explained in this blog post.”
Out-of-Network and Cash-Pay Billing
Is there a good way to get out-of-network fee schedules? How do you know you are being reimbursed correctly for out-of-network services?
If you’re out-of-network with a payer, then by definition, you’re not on a fee schedule. You must accept the payer’s determination, and then bill the patient for the rest. Ideally, you’ll contact the payer to verify benefits in advance and then provide the patient with an out-of-pocket estimate prior to beginning treatment. You’ll also need to decide whether you will accept assignment. In many cases, if you’re out-of-network with a payer, you’ll want to decline assignment, because that way, it’s totally on the patient to work with the payer—not you. To learn more about out-of-network billing and accepting assignment, refer to this blog post.
What’s the best approach to setting a fee schedule if you’re a mostly cash-based practice that also contracts with Medicare? Is there an amount that is too high? What happens if your rates are too high?
According to Wallace, it is acceptable to have different fee schedules for Medicare (or commercially insured) patients and cash-pay patients. He says a good frame of reference for your insurance-based fee schedule is to reference the Medicare allowed amount in your area for each service and set your rates 25–40% higher, which will put you in the 50th percentile range. For cash-pay patients, you can let the market set the rates. Keep in mind that cash-pay patients may have high insurance deductibles, or their insurances may be out-of-network. Depending on your core clientele, you may want to consider providing those patients with superbills so they can attempt to obtain reimbursement directly from their insurance company. Or, you could submit claims to their insurance on their behalf.
What is a superbill?
A superbill is much like an invoice, but for insurance reimbursement purposes—specifically when the provider is out-of-network or the patient pays out of pocket. It includes all of the patient’s treatment and billing information for a particular date of service (e.g., billing codes, diagnosis codes, etc.). The provider gives this document to the patient, and the patient presents the document to the insurance provider for reimbursement. Alternatively, the provider can submit this document to the insurance on the patient’s behalf.
Is it recommended to have the same fee schedule for in-network and out-of-network payers?
By definition, if you’re out-of-network with a payer, then you don’t have a fee schedule with that payer. However, if you draw up a cash-pay fee schedule, then you may not want to copy your in-network fee schedule—especially if your reimbursement rates are less than ideal. Patients often expect higher out-of-pocket rates, so you’re beholden only to what your local market will support.
I own a small private pay clinic. Do I need to adopt the new OTA modifiers in January and charge a 15% difference to clients based on whether their treatment was provided by an OTR or an OTA?
Nope! The PTA and OTA modifiers are Medicare-specific, and thus do not apply to your cash-pay billing process.
What does it mean to accept assignment?
When you’re out-of-network with a payer, your decision to accept or decline assignment determines whether the payer pays you or the patient. When you accept assignment, you indicate that:
- You’re overseeing the patient’s case;
- You will receive payments from the patient’s payer; and
- You will accept the payer’s rates.
When billing out-of-network, you don’t have to accept assignment. If you decline assignment, you’ll collect your full fee from the patient at the time of service. To learn more, check out this blog post.
When billing CPT codes for self-pay patients who may or may not submit a superbill to their insurances for out-of-network coverage, how important is it that we bill units consistently with Medicare? For example—when I work with a Medicare patient, I usually bill four units during a 55–60 minute session. However, when I bill a self pay patient, I usually bill only three units, 20 minutes each. Is this incorrect or wrong?
We would recommend calculating billed units consistently but applying a different fee schedule for cash-pay (i.e., out-of-network) patients.
We’ve noticed that benefits (as listed on payer websites) do not reflect on some patients’ EOBs. For instance, a benefit will say that a patient’s deductible does not apply to PT—but the visits process under the deductible. Why is this happening?
As noted in our response to a previous question, payer websites sometimes do not reflect the most up-to-date—or most accurate—coverage information. For this reason, we always recommend contacting the payer to verify each individual patient’s benefits. And even then, payer reps sometimes provide inaccurate information. Ultimately, it’s the patient’s responsibility to know the details of insurance coverage, but it’s also a good idea to inform patients of the possibility that their payer may misquote your practice regarding benefits—in which case those patients will be responsible for any unpaid amounts.
When verifying patient benefits, insurance reps and websites often relay inaccurate information. What recourse do we have when a payer misinforms us about a patient’s coverage? (For example, we’re told no prior authorization is required when in reality, it is.)
As we explained here, “Ultimately, patients are responsible for knowing their benefits. But, as we all know, patients tend to not do their homework before accessing care—which means the burden of education often falls on providers.” In Jannega’s former clinic, staff cautioned patients from the get-go that they may have received incorrect information. And while we certainly encourage clinics to continue verifying benefits on behalf of their patients, it’s important to be aware that “virtually every insurance company has developed a written rule about how insurance reps are not responsible for inaccurate over-the-phone quotes.” We recommend making your patients aware of this payer tactic, as well. That way, if the payer ends up not covering something and the patient is left footing the bill, that patient is more likely to understand that it isn’t your fault, but rather the payer’s.
Secondary and Supplemental Plans
If a patient has both a primary and secondary insurance, and the primary does not cover our full fee, how much can we charge the secondary? Does this work the same if the primary is Medicare?
First, let’s say the patient has Medicare and a supplemental plan. Medicare will process the claim as normal, and then the supplemental plan will pay the remaining balance of the allowable amount. If the patient has Medicare and a true secondary plan, the secondary plan will apply its own payment rules to the remaining Medicare allowable amount.
With commercial payers, it gets a little tricky. After the primary insurance pays, you have to attach the remittance advice or the patient’s explanation of benefits (EOB) from the primary payer to the claim and send it off to the secondary payer. That way, it’ll know what to adjudicate on claim.
How do balance billing rules change when there’s a second primary insurance (not a supplement plan) involved?
First off, as explained in this AAPC forum, it’s important to understand that while “dual coverage is legal and possible…it’s not a ‘two-primary’ situation.” In other words, even if a patient has two “primary” insurance policies, one payer still functions as the secondary—meaning it will adjudicate the remaining billed amount after the first insurance pays. It’s also important for the provider to accurately calculate what the patient owes—and can legally pay—after both payers have processed the claim, being careful not to issue unwarranted reimbursement for overpayments. For more information on what is and is not allowed with respect to balance billing, refer to this blog post.
If a Medicare beneficiary has a secondary plan (such as a cost-sharing plan rather than traditional health insurance), is it required to bill the patient directly for the co-pay that Medicare does not cover?
We recommend always collecting a patient’s copay, coinsurance, and/or deductible upfront. After all, as we explained here, “only 21% of patient balances that aren’t collected at the point-of-service are ever collected.” If the patient’s secondary insurance ends up covering any of that patient responsibility, issue an appropriate refund to the patient.
Why are we getting rejections that state we’re using an invalid procedure code when we bill for lymphedema therapy using CPT code 97530?
The most common cause of denials in these scenarios is that the payer is adhering to either a local coverage determination (LCD) or medical policy regarding lymphedema coverage. So, review the payer’s medical policy. If the payer is Medicare, look at the LCD. This should tell you which diagnoses need to be on the claim, and how the service should be billed. Keep in mind that many payers have specific payment policies for lymphedema treatment.
Can we bill codes 29581 and 29584 to offset the cost of our wrapping supplies at our lymphedema practice? From what we understand, we cannot separately bill for supplies that are used in our office. Is that correct?
Gawenda says that when billing Medicare, you can bill 29581, 29582, 29583, or 29584 for wrapping on the same day that you bill 97140 for manual lymph drainage. However, this may not hold true for commercial payers.
Which codes can we bill for pelvic floor therapy? Can we bill anything other than 97110, 97140, 97530, and 97535?
You can bill the most appropriate codes for whatever therapy services you provide, but you’ll first want to check with the payer to make sure it doesn’t have a separate policy for pelvic floor therapy. Payers are typically very explicit about the ICD-10 codes they expect to see for specific types of therapy—as well as the treatment codes you can bill with each diagnosis code.
Can I bill for wound debridement? If so, which code should I use?
Usually, yes. Therapists can often provide (and bill for) active wound care management with codes 97597–97606. However, some states do require that PTs obtain authorization from other healthcare professionals prior to providing the service. Check your state practice act to see if wound care management falls under your scope of practice—and if there are any rules unique to therapists providing these services in your state.
Can you bill a workers’ comp payer for manual therapy (97140) the same visit you bill for a work conditioning session (97545)?
In theory, yes. According to Wallace, many payers have established a separate approval process for hardening and conditioning services. When verifying a patient’s coverage, confirm the payer’s protocol for processing claims for both types of services. Some payers may not approve billing these services at the same time—but if they do, ensure that your documentation clearly demonstrates that the manual therapy was performed separately from the hardening and conditioning services.
Can we bill 97530 for a telehealth session?
That depends on the payer policy. As Wallace noted during the webinar, some may not cover therapeutic activities under their telehealth policies. Fortunately, most payers have posted their telehealth policies front and center on their websites, so they should be pretty easy to find.
Can you bill both telehealth and in-person office visits for the same case? For example, I performed the initial evaluation via telehealth, then eventually switched over to in-person visits for the following sessions.
Yes! Therapists may provide both virtual and in-person visits to a patient during the same case—in fact, during the COVID-19 pandemic, we believe it’s best practice to do so. Just be careful not to bill for virtual and in-person services during the same visit—that would be contradictory and could lead to denials.
The 8-Minute Rule
Are evaluations untimed?
Yes! PT, OT, and SLP evaluations are untimed services.
Can I bill two units of 97110 and two units of 97112 during a 46-minute treatment session?
It depends. If you’re using CMS’s 8-minute rule to determine how many units to bill, then you can only bill three total—two units of the service you spent the most time providing, and one unit of the other service. However, if you’re using the AMA’s Rule of Eights to determine how many codes to bill, then you can bill four units. Many payers use CMS’s 8-minute rule, but some do not. Check in with each payer to see which rule it follows.
Is the CPT code 29581 an untimed code?
Yes. According to Rick Gawenda, CPT code 29581 is untimed.
What is the maximum number of units I can bill for a 60-minute session?
That depends! If you’re billing under CMS’s 8-minute rule, then you can only bill four units max during a 60-minute session. However, if you’re billing under the AMA’s rule of eights, then you could theoretically bill seven unique units during a 60-minute session. That’s very unlikely, though.
How many units am I allowed to bill during one session with a Medicaid patient?
Because Medicaid is a state-run program, the rules around maximum allowed units vary from state to state. Reach out to your state’s Medicaid agency (here’s a contact directory) or your state’s therapy professional association to verify the rules for your location.
If I am providing a combination of manual techniques (e.g., therapeutic exercise, therapeutic activities, and neuromuscular re-education), what’s the optimal way to bill for them considering that they’re integrated and not separate activities?
Remember that these are all separate services—regardless of how you choose to deliver them. Bill for them the same way you bill anything else: count the minutes spent providing each service, and follow the 8-minute rule (or rule of eights) to determine how many units you can charge for each.
Practically speaking, what is the difference between therapeutic exercises (97110) and neuromuscular reeducation (97112)?
According to Wallace, therapeutic exercises are dynamic activities that are intended to improve performance. They’re typically big body, multi-segment movements (e.g., lifting, carrying, squatting, pushing, and jumping) that help improve functional performance. Neuromuscular reeducation revolves more around providing education and feedback (e.g., through talking, touch, or taping) to the patient about the quality of movement or how the movement is performed. He recommends only billing 97110 when other interventions don’t apply.
What is the proper verbiage on how we should document “separate and distinct” when we bill manual therapy (97140) and therapeutic activities (97530) together during a single visit?
During the webinar, Wallace mentioned that therapists should include a statement in the daily note explicitly stating that the two services were separate and distinct. That said, the most ironclad way to demonstrate that two services were delivered separately and distinctly from one another is to denote a specific start and end time for each. For example, indicate in the note that you performed therapeutic activities from 1:10 PM to 1:25 PM and manual therapy from 1:25 PM to 1:40 PM. While it is a lot of extra work, it is the only way to unquestionably prove that the services were independent.
Is the massage therapy code ever appropriate to use with patients, and if so, is it ever covered by insurance?
In most cases, physical therapists can bill the massage therapy CPT code (97124) whenever they provide therapeutic massage to a patient. That said, you should always check the individual payer’s policy.
However, as WebPT’s Kylie McKee mentions here, “If you provide both manual therapy (CPT 97140) and therapeutic massage during the same treatment session, you may only receive payment for one of the associated CPT codes. The exception would be if you provided these services in separate 15-minute increments. If that is the case, affix the 59 modifier to the claim and be sure your documentation supports this.”
Additionally, under Medicare Part B, physical therapists must affix the GP modifier to CPT code 97124 to indicate that this service was performed under a physical therapy plan of care.
How much should we charge for the new code 99072—and which payers are paying PTs for it?
As of October 2020, CMS has not announced its reimbursement policies for 99072, and it’s unclear whether or not it will be covered under Medicare. As for other payers, we strongly urge you to contact your state Medicaid programs and commercial insurers to determine whether they’ll accept and pay for this code.
How do we bill for outpatient home visits?
WebPT’s Melissa Hughes actually wrote an entire blog post on this topic. You can check that out here.
What CPT code can be billed when a PT is monitoring vital signs when a patient is resting between exercises?
Monitoring a patient’s vital signs is technically considered assessment and management time. While there isn’t a specific CPT code for this, you can (and absolutely should) count this time toward the codes you plan to bill for the encounter. Just be sure to justify this time in your documentation.
What is risk adjustment—and how does it affect physical therapy?
According to this AAPC resource, “Risk adjustment is a method to offset the cost of providing health insurance for individuals—such as those with chronic health conditions—who represent a relatively high risk to insurers. Under risk adjustment, an insurer who enrolls a greater-than-average number of high-risk individuals receives compensation to make up for extra costs associated with those enrollees.” You can learn more about the federal government’s risk adjustment program by reviewing the resource linked above, but a potential indirect effect on physical therapy is that individuals who may not have been able to obtain insurance coverage without risk adjustment are now more likely to be able to get covered—and thus, seek covered physical therapy services.
Will WebPT ever fully integrate with a billing software?
WebPT offers several robust billing software integrations, which you can review in detail here.
What is the fastest way to verify that our therapists are credentialed under different chapters of BCBS? Our previous biller retired and did not leave behind any information for us.
Check to see if your therapists have accounts through CAQH ProView®, a credentialing database. If they do, they should be able to see a list of organizations that they’re credentialed with. Beyond that, you may have to call each individual payer and verify each therapist’s preferred provider status.
Should I bill with both the treatment diagnosis and the medical diagnosis?
As we explain here, “The treatment diagnosis is the one that represents the injury or condition that you, as the therapist, are treating.” As such, it is also the diagnosis code you should include on the claim so that you can properly justify the treatments for which you are billing.
I own a private practice but also provide PT services to patients in an adult daycare center. Do I need to enroll the center’s address with Medicare and other contracted insurances? What POS code should I use when billing?
Yes. If you provide PT services in both locations, then both locations must be on file with CMS and all your commercial payers. Wallace suggests amending your Medicare information via PECOS or CMS-855B (in addition to your commercial payer information) as soon as possible. As for a POS, Wallace says a location of that nature would use POS 11, to represent an office.
Got more hair-raising billing questions? Comment below, and our team will go forth (think Ghostbusters) and help you conquer your billing nightmare!