FAQ: Physical Therapy Live Billing Q&A: John Wallace and the Case of the Baffling Billing Bylaws

There’s nothing like a good mystery during the Halloween season to get into the spirit. But, grappling with mysteries of the billing variety can make a rehab therapist’s work feel more like a horror film than a detective story. That’s why we called upon our physical therapy billing detectives, WebPT SVP of Revenue Cycle Management John Wallace and WebPT co-founder and Chief Clinical Officer Heidi Jannenga, to help crack the most challenging billing cases our viewers had during our most recent webinar.

And because there’s no shortage of mysteries when it comes to billing, we had far more questions than we could answer in the time allotted. That is why we’ve assembled the most frequently asked into this blog post, where we’re offering answers with the aid of our own billing Sherlock Holmes, John Wallace.

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Multiple Insurance Plans

In cases when a patient has both primary and secondary insurance but the secondary insurance does not cover the full costs left over by the primary insurer, does the patient have to pay the remaining copay?

According to Wallace, you should go by the primary and secondary electronic remittance advice (ERA) or explanation of benefits (EOB), as these will assign the proper balances to the patient according to their rules (if you are in-network).

If we do not accept a patient’s primary insurance but we accept their secondary insurance, do we still have to submit a primary claim?

In this scenario, Wallace advises that you would typically bill the primary insurer, wait until you receive an out-of-network denial, and then submit the claim to the secondary insurer and accept their determination of benefits.

CPT Codes

When is it appropriate to use CPT code 97750 (physical performance test or measurement)?

This is a great question and one we often receive. You can bill this CPT code when you provide a physical performance test or measurement. So, what exactly does that entail? Taking a leaf out of our friend Rick Gawenda’s book (or in this case, blog post), examples of when you can bill for 97750 include (but are not limited to):

Berg Balance Test,
Tinetti,
Timed Up and Go test,
Purdue Pegboard Test,
Isokinetic/isometric strength testing,
Four Square Step Test, and
Dynamic Gait Index.

Gawenda also notes that you can only bill for 97750 when the service is distinct from an evaluation or reevaluation and that this testing “may be manual and/or performed using equipment.”

Can we bill 97750 with other codes on the same day?

Looking again to Gawenda’s blog post on CPT code 97750 (referenced above), he mentions that the billing rules around 97750 change based on the payer, so you’ll have to reach out to each of those insurance companies separately. However, Gawenda does mention that “[n]ationally, the Medicare program does not limit how often this CPT code can be billed; however, your Medicare Administrative Contractor may limit how often this CPT code can be billed and/or how many units they will pay when the CPT code is billed.”

Wallace does emphasize that 97750 can’t be billed on the same day as PT or OT evaluation codes or reevaluation codes, so clinicians should be mindful of that as well. If ever in doubt about best 97750 billing practices, placing a call to your MAC can never hurt.

Wallace notes that in his experience, upper extremity lymphedema does affect upper extremity function and quality of life. He, therefore, recommends checking out the APTA’s Physical Therapy Guide to Lymphedema for suggestions on the correct assessments that can support that claim.

What payers have limited payment to four units? And are these just for timed codes or can we bill four timed codes plus an untimed code, like 97014?

There are a few that have limited payments to four units, Aetna being one of them. However, each payer’s EOB/ERA “Remark Codes” should alert you to whether they’re doing this. And, yes, it counts all interventions timed and un-timed interventions.

How do we bill for iontophoresis patches that patients wear while at home given that we’re not spending more than eight minutes with the patient when setting these up?

According to Wallace, you should bill the patient in cash for the patches.

Does DX code R60.9 always need to be added when using CPT code 97016? Or is it only for specific payers?

The best way to answer this question in terms of specific payers is to consult your payer representative, but we can still provide you with some background as to the best practices when using 97016.

CPT code 97016 is used when a vasopneumatic compression device is applied to one or more areas during a treatment session. While specific use of an ICD-10 code is dependent on the specific payer, CMS and other regulators have given guidance to successful reimbursement for this code:

97016 is a service-based code and will always be billed as one unit only
the medical record should reflect medical necessity
the documentation should reflect objective changes in edema with pre- and post-measurements and any functional impairment and/or gains related to 97016 being applied

What is the most appropriate way to bill patient education?

The specific CPT code for patient education is 98960, but as noted in the webinar, some payers are not reimbursing for this CPT code when it is applied. Instead, workarounds exist to ensure you are being paid appropriately for the skilled services you are providing.

Therapeutic activity (97530) and self-care/home management training (97535) are possible CPT codes that could encompass education that is delivered to the patient. Education in a home exercise program while performing said exercises can also be included under therapeutic exercise (97110). However, if a specific payer is denying claims related to education through a specific code or via documentation, reaching out to the payer is the most direct method of resolution.

MPPR

Do MPPR reductions apply to every CPT code that is billed more than once for one date of service?

According to Wallace, MPPR is applied to each unit of service after the highest valued unit is paid at 100; all other units of services are discounted at 59% of the RVU practice expense.

Do commercial insurance apply MPPR rules, too?

In some instances, yes. And when they do apply MPPR rules, these can vary from CMS’s MPPR rules. To that end, we recommend reaching out to the commercial payers you contract with to determine if they do apply MPPR rules, and what the specifics around those rules are.

Modifiers

If we go beyond the $3,000 Medicare therapy threshold, will we be subject to an audit?

Medicare’s therapy threshold has long been a scary elephant in the room that has deterred no small number of rehab therapists from ending services earlier than desired or anticipated. But do not be deterred by this fancy term that really just means an audit. We have published a number of resources to assist therapists on how, when, and why to continue treatment past the threshold. It basically comes down to well-documented medical necessity.

If you can defend the medical necessity that services continue and this is well documented, then there should be little to fear. On top of that, the increased focus on evidence-based practice should give further credence to sticking to the protocols of LSVT BIG.

Does manual therapy still require the 59 modifier if billed with an evaluation? And is modifier 59 still required for therapeutic activities, as well as therapeutic procedures?

For the initial evaluation, modifier 59 is not required if manual therapy is done during the same visit, and as of 2021, it is not required for a reevaluation, either. As seen in scenario 10 of our recent modifiers quiz, modifier 59 is no longer required by Medicare to pair therapeutic activity (97530) and therapeutic exercise (97110). However, as Wallace mentioned in the webinar, some commercial payers have ignored this guidance, so be sure to pay attention to which payers you are or are not assigning modifier 59.

Do Medicare Advantage plans require the CQ and CO modifiers for assistants for payment reduction?

Wallace recommends checking the payer medical policy as it differs by payer, as Medicare Advantage is Medicare Part C, not Part B, and as such has significant leeway to set their own policies.

NCCI Edits

What are the new Medicare NCCI Edits for physical therapy?

You can find the most recent Medicare NCCI Procedure to Procedure Edits on this CMS page.

For NCCI edits, should we still be using the 59 or XU modifiers?

Depends on the combination of codes you’re billing for. Per Medicare’s NCCI Coding Policy Manual (specifically, chapter 11 under section P. Physical Medicine and Rehabilitation), “[s]ome NCCI PTP edits pair a ‘timed’ CPT code with another ‘timed’ CPT code or a non-timed CPT code. These edits may be bypassed with modifier 59 or XU if the [two] procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter. The NCCI program does not include all edits pairing [two] physical medicine and rehabilitation services (excepting ‘supervised modality’ services) even though they shall not be reported for the same fifteen-minute time period.”

The APTA helps break down this chapter’s contents in its NCCI code edits FAQ here.

ICD-10

Unfortunately, M54.50 was given the proverbial ax when CMS deleted it from the ICD-10 list in October of 2021. Many therapists have since switched to vertebrogenic low back pain, M54.51. For more information, check out the comprehensive blog post we put together on the M54.50 change.

Can a patient be seen on the same day, for two different diagnoses (body parts being treated) with two different scripts at the same outpatient clinic (tax ID number)? Or do they need to be seen on different days?

There are multiple factors to consider in this answer, so let’s first start with the referring physician. If the referring physician for each diagnosis is different, then two separate cases (e.g., different plan of care (POC), different claims) need to be created. However, if the referring physician is the same for both diagnoses, then you have to consider these two scenarios:

If the diagnoses are similar—say a shoulder and a wrist or neck—then they could be lumped together in the same POC.
If the diagnoses are completely different—say low back pain and Parkinson’s Disease—you may want to consider splitting it into two POCs and therefore two cases.

Regardless, Wallace states that the concept of a visit does not exist for payers, and therefore you can bill everything on the same day. However, if your payer limits you to four codes, and four codes or units are not enough, then you might want to treat on different days.

We dive much deeper into this topic in this blog post.

Certain payers will not pay for Temporomandibular Joint Disorder (TMJ) PT treatment, so what are the best ICD-10 codes for these patients?

The ICD-10 code M26.6—with subsequent code subclassifications—applies to TMJ. The best option in this instance would be to reach out to the specific payers to ascertain why claims are being denied and how to rectify this.

Medicare Specific

What are the regulations on the type of fees not billed to Medicare but to the patients?

According to Wallace, only Medicare non-covered services (as opposed to not medically necessary services) can be billed to the patient. He suggests using an ABN and billing with a GX modifier in those cases. If the service is usually covered but is not medically necessary in your particular case, he recommends having the patient sign the ABN and bill with the GA modifier

When unsure of how best to proceed with any payer, following CMS guidelines is a good cover-all in a “need to know now scenario,” but we recommend reaching out to your Medicaid representative on specifics as the rules vary greatly from state to state.

We are currently a participating provider with Medicare (and approximately half of our patients have Medicare), yet we are having a problem making a profit after receiving their reimbursements. Is it common to become a non-participating Medicare provider?

You can become a non-participating provider, but as Wallace says, that may not solve your problem. He recommends looking at the number of 15-minute codes you bill to Medicare—three timed units per visit should get you into the mid-$80 per visit range, while four timed units should get you into the low-$100s per visit range. If you aren’t in those ranges, you are likely underbilling. If you’re falling short of this mark, Wallace suggests allowing more time for each Medicare visit (approximately 40-60 minutes) so you can get to three to four timed units per visit.

Remote Therapeutic Monitoring

Can you discuss the new billing codes for remote therapeutic monitoring (RTM)?

Indeed we can—and in fact, have! Here is a list of resources we’ve create that will provide you with all the information you need on RTM (and then some):

Also, keep an eye out for our large-scale RTM guide, which we’ll be publishing in late November!

Any tips on billing for remote therapy monitoring (RTM) codes?

Yes indeed! As we outlined in this blog post, “[e]ach RTM code varies slightly in terms of how often it can be billed. See here:

Code 98975 may be billed once per episode of care, which starts when the remote therapeutic monitoring service initiates and ends once targeted treatment goals are attained.
Codes 98976 and 98977 may be billed once per 30 days.
Code 98980 may be billed once per calendar month for the first 20 minutes of care, regardless of the number of therapeutic monitoring modalities performed in that calendar month.
Code 98981 may be billed once per calendar month for each additional 20 minutes completed within that month.”

Now, how can you successfully apply these in practice? We’ve got a few ideas on that front, too, and took a deep dive into suggested strategies in this blog post. And for national payment amounts for each of the RTM CPT codes, take a look at the handy chart we embedded in this blog post here.

Medical Review, Authorizations, and Accreditation

Can you submit progress notes to Medicare before the tenth visit? Or is it a hard requirement on the tenth visit?

Let’s start by clarifying the tenth visit rule. Although some clinics and therapists use the terms “progress note” and “reevaluation” interchangeably, the rule only applies to progress notes. What’s more, Medicare (and most commercial payers) treat them very differently, and thus requires providers submit progress notes for every patient by at least their tenth visit. The key term here is “at least” because if the clinician decides to do a progress note on the fourth or eighth visit instead of waiting until the tenth, then that’s perfectly acceptable. Note that whenever the progress note is completed, the clock will reset until the next one is due (at or before the next tenth-visit mark since the last submission).

How often should an over-90-day A/R account be worked?

Wallace recommends working A/R every month at the minimum and notes that some practices work accounts every two weeks if a patient is not responding.

Please explain the difference between recertification and reevaluation.

These two terms are often used interchangeably—and in many instances can be—but this can sometimes lead to confusion and costly errors. In short, a recertification (in Medicare terms) applies only to a certification period of 90 days that—for whatever reason—needs to be renewed, while a reevaluation is done independent of time constraints when there is a change in the patient’s status, goals, or diagnoses that requires a change to the POC.

Furthermore, reevaluation is a billable code whereas recertification is not—but both of these do require a physician’s signature and are often completed together. Gawenda has a helpful blog post describing how a progress note, reevaluation, and recertification can all be on the same note if done correctly.

Credentialing

How do you bill for per diem PTs who are not contracted?

Let’s start by clarifying two terms: credentialing and contracting. In all likelihood, your practice has already been contracted with a payer, but the per diem PT is not credentialed with the payer and therefore is out-of-network. However, all treating therapists must be credentialed to be considered in-network providers, so you will need to get the per diem PT credentialed as soon as possible. But in the short term, we have to figure out how to keep your business running.

One solution is to have another, credentialed PT cosign on any notes to payers the per diem PT is not credentialed with. Another option would be to bill the services as out-of-network per each payer’s guidelines for out-of-network providers. (This route may be less desirable for patients though.) Lastly, if your patients are Medicare beneficiaries, then Medicare allows you to hold your claims until your credentialing application has been completed.

We have compiled numerous educational posts on the ins and outs of contracting and credentialing, and WebPT offers credentialing assistance as one of its many member benefits.

Cash Pay

As a cash-pay therapist, can I treat a Medicare patient who wants to pay for their treatment in cash?

This depends on the type of relationship you have with Medicare. If you are a participating provider with Medicare, you can’t accept cash payments from patients for covered services. If you’re a non-participating provider, you can accept payment directly from the patient, but you must bill Medicare directly for any covered services in order for the patient to be reimbursed. For providers with no relationship with Medicare, you once again cannot provide covered services to Medicare patients on a cash-pay basis.

Do we have to follow Medicare guidelines for Medicare Advantage patients?

Wallace states that it can depend on the plan, as Medicare Advantage (MA) is Medicare Part C and thus providers are not required to follow the Part B rules—although many MA plans do use some of the Part B rules. He recommends consulting their medical policies to be certain. Keep in mind that if you’re an out-of-network provider, you aren’t required to follow either of their policies. If you don’t follow those policies, though, you should advise your patients that they may get less reimbursement as a result.

Dry Needling and Other Nontraditional PT Services

Can you bill e-stim G0283 (unattended) with dry needling codes 20560 or 20561?

According to Wallace, it is permissible to bill an untimed modality at the same time as a timed procedure (e.g., 97112 with 97014/G0283). He does note, however, that if the payer does not cover dry needling, they may not allow the G0283 charge.

Are there any updates to billing for dry needling, especially for plans that are not standard Medicare?

Currently, Medicare and about half of all commercial plans do not cover dry needling. If their determination is that dry needling is a “non-covered” service (as it is with Medicare), you can collect from the patient. If the payer’s determination is that it is not medically necessary, and you are in-network, you cannot bill the patient.

Acute Care

In acute care, what do I need to know about billing patients who are under “observation status,” “outpatient in a bed,” (i.e., elective joint replacements), and ER patients? More specifically, does billing for these types of patients differ from a standard admitted patient?

Oftentimes, “observation status” signifies a patient has not yet been admitted. But, it’s

best to clarify with your hospital what “observation status” means with respect to patient admittance because it will determine whether Medicare Part A or B will cover the costs. Here’s why:

Patients with a signed order from the attending physician for admittance to the hospital will be covered under Medicare Part A (inpatient services).
Patients that have not been admitted will be covered under Medicare Part B (outpatient services).

If the patient is in observation for two days and then admitted on day three, then the patient is an admit and Medicare Part A pays for everything but the doctor services that are covered under Part B. Still confused? Luckily, Medicare has this reference tool to give scenarios of when Part A or B would apply to a patient in observation.

Home Health

How can you reduce recoupments for home health?

Wallace recommends calling the home health agency and asking for the discharge date from their service.

Telehealth

If telehealth continues to be supported in our state, but isn’t considered a covered service by payers, would our patients be able to privately pay to receive these services?

Yes, as long as it’s not covered.

Can telehealth be performed for a patient who is out of state (e.g., can a PT in New York work with a patient in California)?

That depends, as the rules for delivering telehealth across state lines depend upon each state’s laws as well as federal policies—all of which are outlined in this Department of Health and Human Services article.

Now, if you’re working between states that are both a part of the PT Compact, cross-state telehealth becomes much, much simpler. However, if that’s not your situation, we recommend reviewing this guide that covers which states are waiving licensure rights for telehealth in response to the public health emergency (which we are still currently in).

Co-Treatment

If two therapies are rendered at the same time (such as PT and ABA therapy), are both billable to commercial payers?

With the seemingly infinite number of commercial plans that exist, it’s impossible to provide a finite, universal answer to this question. Your best bet is to call the payers in question directly to fully understand their reimbursement rules on this topic. To avoid sending you into the lion’s den unprepared, however, here are a few links that give guidance on co-treatment as well as feedback on the need for ABA to be done in tandem with other rehab disciplines.

Billing

We are seeing more payers move to a per-visit rate vs. a per-unit rate. Do you think that’s a trend that will continue?

While some parts of the country are much further down this road than others, Wallace does note that per-visit rates are a trend on the rise, and predicts that until payments are dependent on outcomes or become value-based, this will continue to happen. He also suggests that if your payments dip too low, you can move out of network.

If we are out of network with BCBS, can we accept the in-network copay as payment in full?

Yep!

If I want to go out of network with Aetna, can I still see patients with an Aetna Medicare Advantage plan and have them pay with cash?

Per Wallace, you’ll have to check and see if that plan has an out-of-network benefit, as not all plans do. If there aren’t out-of-network benefits—and you are out-of-network—then your services are non-covered and you can bill the patient directly.

What are some examples of cost-effective ways to skip trace?

Wallace mentions that you can spend $20 to $60 a month on services like Tracers and Skip Genie to help tackle the problem, depending on the number of patients you’re looking to track down. If you’re looking to pay on a per-trace basis, there are other, more cost-effective options that can help!

Denials and Appeals

How far back can a denied claim be reworked?

According to Wallace, the threshold for reworking claims depends on the timely filing requirements of the payer in question. You’ll have to do a little reconnaissance on your own to answer this question.

How do we know which claims should be appealed, and which aren’t worth the effort?

Wallace recommends reviewing the reason for the denials, which are listed as “Remark Codes” on the ERA/EOB. If it’s timely filing, not medically necessary, or non-covered, then appealing is a waste of time in Wallace’s estimation. If it’s a medical policy denial, check the payer’s policy and appeal based on the fact it’s a covered service and you met the criteria.

We have had Medicare patients reach their cap and generally been able to rebill with a KX modifier. I’m noticing that they are not allowing rebills anymore and are requiring an appeal. Do you know why?

As Wallace notes, rebilling and filing a corrected claim is not the same thing. He recommends checking the MAC’s redetermination policies and process on their website to see how you need to resubmit these claims.

And just like that, rehab therapy billing has been reduced from a horror story to an approachable FAQ, thanks to super sleuths Wallace and Jannenga.

For even more billing information, be sure to check out our comprehensive rehab therapy billing guide. And don’t forget to check out WebPT’s billing software and RCM service options if you’re looking for some extra support on the compliance and reimbursement front.