Code changes, denials, and audits, oh my! Who could possibly solve all the billing quandaries PTs, SLPs, and OTs encounter every day? There is one who can. Okay, well, at least one we’re proud to call our very own: WebPT’s John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management. Recently, John and Heidi Jannenga, PT, DPT, ATC, WebPT co-founder and Chief Clinical Officer joined forces to address some of the most baffling, mystifying, and downright frustrating rehab therapy billing issues. And, while they covered tremendous ground during our hour-long webinar, there are more questions to answer (sorry, John, a billing expert’s work is never done!).
For those of you who asked a question that wasn’t addressed during the webinar, we did our best to answer them below. However, we received more than 500 questions in total, so we had to whittle them down to the ones we felt were most relevant to our readers. (Otherwise, you’d be reading this until next year’s billing webinar!) So, find a comfortable spot, kick up your feet, and enjoy this collection of billing brain busters.
Does Medicare policy influence how much or little I can bill my cash-pay clients?
Yes and no. If you’re not treating any Medicare patients, then you can cater your fee schedule to the market without worrying about Medicare’s limiting charges. But if you plan to see Medicare patients as a physical therapist and not as a wellness provider, you must either adhere to the Medicare fee schedule as a participating provider, or bill beneath the limiting charge as a non-participating provider. This is because you cannot opt out of Medicare as a PT, OT, or SLP.
What considerations should I take into account when determining my cash-pay rates?
As recently outlined in one of our blogs, John recommends using actual CPT codes to help establish cash-pay rates (e.g., one unit of 97110 costs $35). Doing this makes it easier for patients to bill their insurance companies if you aren’t doing so on their behalf. He also recommends using ICD-10 codes for the same reason. Additionally, consider things like local market demand, Medicare guidelines, and your desired profit margins to help create your cash-pay rates.
What is an ABN for Medicare patients and where can I find a template?
An Advance Beneficiary Notice of Noncoverage (ABN) is a form issued by outpatient Medicare providers to beneficiaries “in situations where Medicare payment is expected to be denied.” Providers can use these forms to different ends depending on whether or not the patient is willing to waive their right to bill Medicare for the non-covered services.
If a treatment doesn't meet the definition of medical necessity and the patient is willing to waive their right to bill Medicare for that service, then you may issue an ABN and set up a cash payment with the patient.
If a service will be non-covered but the patient would like you to bill Medicare, then you may issue an ABN and file the service(s) with a GA or GX modifier, depending on the reason for why the service isn't covered. Use the GA modifier to indicate when a service is usually covered, but not medically necessary. Use the GX modifier to denote a statutorily non-covered service (e.g., dry needling). Just remember that you must—and this is vitally important—have the patient sign the ABN before billing.
You can find an ABN template on the CMS website.
Some Medicare documentation states that you must see patients in their home or in the office, but I have worked at places that take patients on outings to various locations. If you are a mobile provider can you treat someone at the grocery store for a session if this is something they request? If so, what do you put for the service location code on the bill?
Any reasonable extension of the patient’s “home” or your office is valid—as long as it is called out in the plan of care and only lasts a few visits (e.g., golf driving range, car transfers, seat positions, posture positioning). Use the same POS as you would where you normally treat the patient—but in the note denote where the service was delivered and the reason it was necessary.
Medicare Advantage (MA)
Why is Regence Medicare (an MA plan) making us wait three weeks after the Medicare payment date before we can submit secondary claims to them?
We aren’t entirely sure, as there is no requirement to do that.
If you are a contracted Medicare provider, are you automatically contracted with every Medicare Advantage (MA) plan?
Not typically. MA plans are sold through commercial payers, and MA patients typically must be seen by a preferred MA provider. Plus, MA plans are under no obligation to fulfill Part B guidelines. Wallace advises researching each MA plan individually for specific rules and regulations.
Workers’ Comp, Auto Insurance, and VA Payers
If your patient has CHAMPVA, but your clinic is not contracted with UHC, TRICARE, or the VA, do you have to take the insurance adjustment? Can you balance bill the patient?
You can balance bill the patient, but tell the patient you're not a provider for that plan. If you’re not a provider, the patient payment portion can be an amount you negotiate with the patient.
What’s the difference between TRICARE For Life (TFL), TRICARE West, CHAMPVA, and VA?
TRICARE is the basic equivalent of commercial coverage for military personnel and military dependents. The VA and CHAMPVA programs provide coverage for veterans who have served time in the military.
A Medicare patient was involved in an auto accident. The patient states the auto case was closed and the lawyer said to bill their Medicare. What is the appropriate way to handle this?
This is a complicated area—but from a high-level perspective, indicate what’s going on as best as you can using the 1500 claim form. It has a series of questions about whether the problem you’re treating is related to an accident. When you mark “yes” in the box asking about accidents, you will trigger coordination of benefits with Medicare patients. With that said, Medicare won’t pay benefits until they talk to the patient and the appropriate forms have been filled out. Medicare may pay as a primary in that situation, but you may also expect to be paid once there’s a settlement.
Can you bill for pre- and post-service time spent providing an intervention? For example, if I spend 5 minutes asking a patient about their HEP program, provide 15 minutes of therapeutic exercise, and then spend 5 minutes assessing their response, can I bill for 25 minutes of treatment?
Yes. This is considered assessment and management time—and it’s accounted for in every CPT code. You should absolutely include this time when you’re tallying up the time you spend furnishing services to patients.
What’s the difference between the 8-minute rule and the rule of eights? When should I use one or the other?
The 8-minute rule is a regulation created and used by Medicare to help healthcare providers calculate the number of units that they can bill for the services they provide. The foundation of the rule is this: If a timed service is provided for at least 8 minutes, it equates to one billable unit. But it gets a little more complicated once you begin providing multiple timed services. We recommend keeping a chart like the following on hand for reference.
Though the 8-minute rule was created by CMS for the Medicare program, many commercial payers use it for their own billing practices—though not all do. Some payers instead opt to use the rule of eights—a variant of the 8-minute rule that was created by the American Medical Association (AMA).
The rule of eights is a little more forgiving than the 8-minute rule. It “still counts billable units in 15-minute increments, but instead of combining the time from multiple units, the rule is applied separately to each unique timed service. For example, say a therapist bills 10 minutes of 97110 and 10 minutes of 98116 in a single visit. Those codes are considered unique services, and are counted separately. Each service lasted longer than eight minutes, so the therapist can bill for two units total: one unit of 97110 and one unit of 98116.”
As for picking which rule to use, it’ll all depend on who you’re billing. Medicare (and many commercial payers) adhere to the 8-minute rule, but some commercial payers use the rule of eights. Reach out to individual payers to confirm which rule to follow.
Is it ever appropriate to bill an initial evaluation more than once for the same injury when there has been no surgery or new injury?
If there’s a major change in the patient’s primary diagnosis, then absolutely do another initial evaluation. Additionally, if a patient has been seen in a different clinic and then comes to you for the first time, bill an initial evaluation.
When is it appropriate to bill an initial evaluation instead of a reevaluation?
Generally speaking, if there’s an active plan in place, you’re actively providing care, and there’s been no major change in a patient’s primary diagnosis, bill a reevaluation. Initial evaluations are typically only appropriate for new injuries or major changes to the patient’s diagnosis.
Is there a trick to getting multiple evaluation codes paid within a one-year period?
Unfortunately, this is a payer-by-payer battle, with Aetna as the biggest culprit for denials. Aetna only pays for one evaluation a year—no matter what. But most payers will pay for multiple evals in a year. To get them to accept the claim, simply document defensibly.
I know that you can’t bill for an evaluation through telehealth. But if I provide an evaluation through telehealth and don’t bill it, is that enough for an assistant to provide home therapy off of—and bill for—subsequent visits?
Assuming we’re talking about Medicare Part B, the answer is yes. Just be sure to establish a plan of care as if you were seeing the patient in the office prior to letting the assistant treat the patient. But remember, there are a lot of state-specific rules regarding home health and supervision in the home environment—so this answer may change depending on your location. Be sure to check your state practice act for clarification!
What is the difference between CPT codes 97110 (therapeutic procedure) and 97530 (therapeutic activities)?
There’s a big difference in payment between the two. Billing 97530 results in higher payments because it requires equipment. Beyond that, 97530 promotes functional movement (e.g., a knee extension) whereas 97110 is less about functional movement (e.g., a squat).
What is the proper use of CPT code 97150? How should I document it—and bill for it?
This is the group code for treating two or more patients when, instead of providing one-on-one care, you’re providing skilled intervention to two-plus patients at one time. You cannot bill for the group code when you’re simultaneously providing one-on-one therapy to another patient. Note that the patients receiving group therapy do NOT have to perform the same exercises or have the same diagnosis.
To document the group therapy code, point out that you’re providing services to more than one patient at the same time—and stay away from the word “supervise” as different payers may interpret that word differently.
How would you bill the time it takes to perform volume measurements on a limb and create the document?
Use CPT code 97750, the physical performance testing code. It’s a timed code (i.e., you can bill multiple units of it), so track the time it takes to complete the measurements and bill accordingly. Do not bill this code on the same day you provide an evaluation or reevaluation as the functions of this code rolls under evaluations.
What are the most common codes that are billed for pediatric therapy?
It’s tough to say because it depends on the focus of the pediatric therapist and their patients’ needs. That said, many pediatric therapists bill similar codes as their PT, OT, and SLP peers because you can use the same codes for children as you do for adults.
It’s worth noting that many pediatric patients are covered under their state Medicaid programs, which regularly use non-CPT codes. So, if you’re trying to learn how to bill for pediatric Medicaid patients, check your state practice act for guidance.
If my patient performs therapeutic exercise and therapeutic activities in the pool at chest or waist level, can I bill those as 97110 and 97530, respectively? Or, must I bill an aquatic therapy code?
Bill the aquatic therapy code for these services as it’s more specific to the service(s) being applied. As an added bonus, you’ll get paid better for aquatic therapy than you will for therapeutic exercise or therapeutic activities.
Can we bill 99368 for a PT participating in a team meeting to discuss a client's treatment plan or evaluation results?
It depends on what’s included as payable in your fee schedule—and that’s part of your payer contract. In regards to Medicare, 99368 is not a PT or OT code, so Medicare will NOT pay—no matter what.
We're having difficulties billing CPT code 95992 alongside the diagnosis H8110. Sometimes Medicare pays it and sometimes they don't—why is that?
Treating patients for vertigo or dizziness issues gets a little complicated because regional Medicare Administrative Contractors (MACs) have different policies about billing for these treatments. We recommend ensuring that you’re billing the correct ICD-10 code for canalith repositioning and then reaching out to your local MAC to ensure that you’re following the correct billing protocol.
Can you explain the recent UHC change (with regard to modifier 59) and the 97140 denials? UHC has reinstituted that edit— and we don’t know why.
UHC has changed its policy and reinstated this edit because they are not forced to follow the current NCCI edits, and decided that this billing methodology made sense for its organization. If you get denials for that edit, file a corrected claim and it should be processed correctly.
What is the correct way to bill for and document dry needling therapy services?
First thing’s first: Do not use 97140 (manual therapy) to bill for dry needling. It is not an accurate way to bill for insertion of the needle. If you do bill for dry needling, use one of the actual dry needling codes: 20560 or 20561.
That said, fewer than half of payers cover dry needling—so receiving payment for it may be a little difficult. If the payer in question deems the service as noncovered, you can bill the patient at the time of service (like a cash-pay model, essentially). But if the payer in question deems dry needling as “experimental” or “not medically necessary” then you most likely will not be able to bill the patient or the payer for the dry needling. At the end of the day, we recommend thoroughly reviewing your payer contracts and speaking with a provider representative to confirm how you should bill dry needling.
Dry needling codes are untimed. If I apply e-stim to the needles, can I bill the dry needling codes with unattended e-stim (CPT code 97014) since they are both untimed? What about attended e-stim (CPT code 97032)?
You can bill one of the dry needling codes with 97014—but you cannot bill it with the attended e-stim code (97032).
Lymphedema and Compression
Which CPT code is the most appropriate for the application of multi-layer compression bandaging for lymphedema?
Generally speaking, 97140 (manual therapy) is the most appropriate code here. And considering how long the service takes, you may be able to bill five to six units of it. That said, most payers have a separate policy for lymphedema, so reach out to your provider representative before providing these services.
Is Medicare paying for CPT 29581 and 29584 for the treatment of lymphedema?
These are strapping codes, so we don’t recommend using them to bill for lymphedema treatment. Use CPT code 97140 because it’s more accurate—and it’s paid better to boot!
Cupping and Hot and Cold Packs
What is the correct way to bill for cupping?
Don’t do it! Cupping is an acupuncture technique and falls under acupuncture policy. Rehab therapists are not authorized to bill for cupping.
I’m a PT billing Anthem for one unit of 97530, one unit of 97112, one unit of 97110, one unit of 97140, one unit of 97116, and one unit of 97014. What modifiers do I need?
This is a pretty simple one! We recommend using the GP modifier if you’re a PT and the GO modifier if you’re an OT.
What are the rules for KX and GA modifiers and the difference between them?
The KX modifier signals that a Medicare beneficiary has surpassed the therapy threshold but the services they’re receiving are still medically necessary. The GA modifier is a modifier that signals that you’ve asked the patient to sign an ABN because—while the service you’re providing is normally medically necessary, you don’t believe it is medically necessary in this instance.
Can you provide a list of the different modifiers used by PTs and OTs and when to use them?
Absolutely! Please check out this blog post.
Is it true that commercial insurances are following Medicare’s lead in that they only cover one style of splint during a five-year span? For example, if a patient received an L3908 pre-op, then received a gel flex (same code) post-op, it would not be covered, right?
It’s tough to answer this one because commercial payers all have their own rules. They may or may not cover orthotics. It’s best to check individual coverage and go from there.
Does CMS still require providers and clinics to be a DMEPOS (prosthetics and orthotics supplier) in order to bill L-codes for splints and orthotics? If so, does this apply to all of the Medicare Advantage plans as well?
CMS (and thus, Medicare) does require providers and clinics to be a DMEPOS for direct billing of custom orthotics. You will need to check specifically for Medicare Advantage plans.
As a PT, what code do I use for molding of orthotics along with the L3000 for custom orthotics? And can it be billed on any visit—or first visit only?
First, to bill Medicare and most Medicaid plans, you must have Medicare DME certification status. Many commercial plans have national contracts for custom orthotics with O and P companies, and if you find a plan that will cover your services, you can bill the L codes. They are global service codes that cover all the components regarding the orthotics: assessment of the patient, lab fees, supplies, instruction, etc. You can bill it any time in the treatment plan.
What documentation co-signature requirements are needed when billing an incident-to a physician?
The physician you’re billing incident-to does not need to sign any documents other than the plan of care—and this is the same in all situations.
Can I ever bill a PTA’s treatments incident-to an MD?
No. Therapy assistants cannot bill incident-to a physician. This was reiterated in the 2022 Final Rule when CMS explicitly stated that therapists must bill the providers who bill incident-to physicians.
Plan of Care (POC) Certification
Can we accept prescriptions or referrals from other chiropractors in Georgia?
To our knowledge, chiropractors cannot sign a plan of care in any state. We recommend checking the Georgia regulations to verify if a Doctor of Chiropractic is considered a licensed diagnostician.
Can we use physician assistants as referring physicians?
Yes; a PA who is working under direct supervision can sign a Medicare plan of care.
If a surgeon leaves a practice, what do we do about obtaining a signed plan of care? Should we continue to bill under his name for continuing patients’ treatments or transfer the care under another surgeon in the group?
The plan of care is valid as signed by the physician until it expires. At that point, you should seek POC certification from another surgeon.
A payer sent me a letter saying I bill CPT code 97110 too often, but didn’t provide any more details. Is there an online resource I can use to learn the parameters of the code?
The best place to learn the parameters of a CPT code is in the most recent addition of the CPT handbook. That said, it probably won’t contain the information you’re looking for. Here’s some general advice, instead:
- If you’re tapping the skills of a PTA to provide 97110, that’s not immediately obvious to the payer. Ensure your documentation clearly shows that you’re working with an assistant to furnish more care than you could on your own.
- You should have a fairly even distribution among the three movement intervention codes: 97110, 97112, and 97530.
What is the billable code for pain in bilateral hips? We have been getting rejections for M25.559 (pain in unspecified hip), M25.552 (pain in left hip), and M25.551 (pain in right hip).
Here’s what Wallace says: “I suggest you use the diagnosis for the cause of the pain. If you are using a more specific diagnosis to describe the cause for hip pain, that is why you are getting the denials.”
What is the most specific code for the aftercare that follows a knee joint replacement?
Use Z47.1 and Z96.65 together.
If we have a TKA patient and they have diabetes, should we list the ICD-10 Diabetes code too?
M54.50 is consistently getting denied by various clearinghouses. Are all insurers following these code changes?
Payers should be following these changes, yes. Check the dates of service for these claims and ensure they occurred on or after October 1—when the M54.50 changes took effect. If these dates of service occurred prior to October first, you can try filing corrected claims, or call and ask if they are using the 2022 ICD-10 codes and when they took effect.
Since a PT cannot diagnose if the main issue is not on the referral, is it possible to substitute a diagnostic code of low back strain for low back pain?
You must talk to the referring diagnostician and get verbal approval of the code you need. Then, send an updated referral form to the doc for signature. If you use a plan of care that you plan to send to the doc, include the new diagnosis. Once the signed plan of care is returned, you are covered.
In the past, PTs were expected to add a "rehab diagnosis" to the referral diagnosis. Do we still do this, or leave it out to avoid the denials?
Leave it out, as the primary diagnosis should be the most specific diagnosis of the problem you are treating.
If I send a claim for a date of service before October 1, but it is not getting to payers until after October 1, which M54.5 codes should I use?
If the date of service occurred before October 1, then you should follow the old M54.5 billing rules. For more information, take a look at this helpful resource.
Can I use the "encounter for other orthopedic aftercare" code for meniscectomies or other arthroscopies—or do I need to be more specific?
That code should be adequate on its own for post-op needs.
How can I properly code autism-related services? Is it appropriate to code F84.0 first—or the reason for treatment?
Always code what you are treating first in the most specific way possible. Many providers are not coding autism at all and instead documenting the diagnosis that’s most specific to the issue and diagnosis that they are treating.
Therapy Assistants and Aides
If a PT works one-on-one for the entire PT session with a Medicare patient, and their PT tech works one-on-one for the entire PT session with a commercial insurance (that accepts PT techs), is it then legal to bill the full time for both treatment sessions, even though one was Medicare?
Yes—but only if your state allows therapy aides and techs to treat patients while being personally supervised by a PT. Additionally, you must be working one-on-one with the Medicare patient while the tech is working one-on-one with the other patient.
What was CMS’s final decision regarding PTA supervision?
There hasn’t been a change to therapy assistant supervision rules.
Is it alright if a patient has two insurances and the second one pays more than the allowable left behind from the first one?
This is a gray area and may be subject to the laws and regulations of your specific state. Also keep in mind that your preferred provider agreement for the primary insurance may prevent you from balance billing more than the allowed amount.
A therapist left our practice and we hired a new therapist to take over that caseload, but they’re waiting on the credentialing process. Can I bill for services rendered by the therapist who’s taking over the caseload, and if so, how?
It depends specifically on the payer and their rules. Some payers may allow a cosigner supervisor, but they usually do not. Once the new therapist is credentialed, Medicare and a few other payers will pay retroactively to the date of the provider application. But ultimately, you should check the provider credentialing rules with the payers in question.
Per your benchmark reports, I see that most clinics provide, on average, four to six units per visit. This would involve billing more than one patient at a time—or overlapping patient care and billing. How do clinics do this from the billing perspective?
There are several factors to consider here. These clinics may excel at capturing their assessment and management minutes—or they (most likely) may be leveraging therapy assistants to provide care.
That said, we’d like to clearly state that if you are providing one-on-one care to a patient and you’re not leveraging therapy assistants or other extenders, you cannot bill for multiple patients in a single time period. One-on-one rules are determined by the CPT codes themselves—not by payers. So if you’re treating more than one patient at a time, you’re providing intermittent care, which must be billed as group therapy.
What is the best way to bill a claim when a patient has more than one case or condition and two different referring physicians?
Create and use two separate plans of care. But if the payer is the same for both cases, be aware that it will not easily recognize what’s happening and be prepared to apply the diagnosis that corresponds to each CPT code used.
Didn’t see your question in the list above? No worries, drop it in the comment section below and our team of compliance sleuths will do our best to answer (or we’ll chase John Wallace down ‘til we get one).