As the old saying goes, “when it rains, it pours”—and if anyone can relate to that sentiment, it’s a physical therapy patient with multiple diagnoses in multiple body regions. Fortunately, your expertise as a physical therapist in all things musculoskeletal can help those patients feel right as rain. Documenting and billing for the care you provide in such scenarios, however, isn’t always straightforward.
So, we put together this handy blog post to help you navigate some common billing scenarios for PT services performed on more than one body part. (Please note: The advice below is based on Medicare Part B rules. While many private payers use the same billing guidelines as Medicare, you should always confirm this in advance.) Read on to learn more.
Same Service; Different Body Parts
As we explain in this blog post, “If you are treating a patient, and he or she presents with a second diagnosis that is either related to the original diagnosis or is a complication resulting from the original diagnosis, you’ll need to complete a re-evaluation and create an updated plan of care.”
Let’s say you’re treating a patient following surgery to repair tears in the anterior cruciate ligaments (ACL) in both knees. If, for example, you provide 15 minutes of e-stim on each side, you would combine the time and bill for a total of 30 minutes—or 2 units—of 97032 (e-stim).
What if the new diagnosis is unrelated?
Now, let’s say that part way through therapy, the patient presents with a subluxation of the left metatarsal. Based on Medicare’s evaluation rules, if the metatarsal injury is related to the original diagnosis, then you would need to complete a re-evaluation and create an updated plan of care that includes both diagnoses.
If the metatarsal injury is unrelated to the ACL injuries, then you would need to complete a new initial evaluation. You could then either create a completely separate plan of care or combine the new plan of care with the existing one.
As for billing, per Medicare Part B rules, if you provide 5 minutes of manual therapy for each ACL injury and 5 minutes of manual therapy for the metatarsal injury, you would combine this and bill for a total of 15 minutes (1 unit) of manual therapy—regardless of whether or not the injuries are part of the same plan of care.
What if the services for different body zones are considered bundled?
As Meredith Castin explains in this blog post, modifier 59 is appropriate when you perform linked services (i.e., services with codes that form NCCI edit pairs) on separate and distinct body parts. That said, in some cases and for some payers, it might be more appropriate to use the XS modifier to indicate that the service was distinct because it was performed on a different structure or organ. (To learn more about X modifiers, which some payers use in place of modifier 59, check out this blog post.)
Different Therapists; Different Body Parts
There are specific Medicare Part B rules governing co-treatment delivered by a PT and an OT. As we explain in this guide, “Therapists cannot bill separately for either the same or a different service provided to the same patient at the same time.” According to compliance expert John Wallace, PT, Chief Business Development Officer of RCM at WebPT, Medicare does not differentiate therapy services provided to a patient under the same tax ID on the same date of service—regardless of whether the providers are PTs, OTs, or SLPs: “For any services given to a patient by therapists under the same tax ID for the same date of service, you’ll have to bill these together.”
Additionally, as mentioned in this blog post, “documentation must clearly indicate the rationale for co-treatment and specify the goals each therapist will address through this method of intervention. Each therapist should document co-treatment sessions as such, specifically detailing which goals the team of therapists addressed and how the patient progresses.” All of that is to say, you shouldn’t co-treat out of convenience; co-treatment is only appropriate if it will benefit the patient, and your documentation must support that benefit. Finally, “therapists should limit therapy services performed during one treatment session to two disciplines.”
A patient is receiving therapy after experiencing a stroke, which has resulted in severe hemiparesis on the left side. The patient is being treated by a physical therapist and an occupational therapist simultaneously. The physical therapist assists the patient with bed transfer for 15 minutes while the OT works with the patient on gross motor IADLs for 15 minutes. Both services are billable under CPT code 97530 (therapeutic activities). Both therapists may document separately while noting the services took place alongside the other discipline. However, when billing for these services, the therapists would bill for a total of 30 minutes of therapeutic activities and apply the appropriate therapy modifiers as follows:
- GP: 97530, 1 unit
- GO: 97530, 1 unit
Please note: In the case of non-Medicare payers, the payer may deny the codes initially. To receive payment, you’ll need to appeal this denial and note that each instance of the code was provided by a different therapist.
Alternatively, if the patient was working with two PTs simultaneously and each PT provided 15 minutes of therapeutic activities, you would combine this time and bill as follows:
- GP: 97530, 2 units
What about bundled services?
Furthermore, “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.” In other words, for billing purposes, apply the 59 modifier as if all the services were delivered by the same therapist.
For example, if one therapist bills 1 unit of 97110 and another therapist bills for 97763 on the same date of service for a Medicare beneficiary, you would need to affix the 59 modifier, as these two codes form an edit pair under Medicare Part B.
Different Body Parts; Different Payers
On a rare occasion, you may treat a patient for two separate complaints where one payer is responsible for the first complaint and another payer is responsible for the second. In this instance, you can split the billing into two separate claims—one for each payer.
Let’s say you have a patient who is simultaneously receiving treatment for a work-related back injury and vertigo that is unrelated to the work injury. The patient has a commercial payer that will cover treatment for vertigo, and workers’ compensation will pay for the work-related injury. In this instance, you may submit two separate claims—one for the commercial payer and one for workers’ comp. For each diagnosis, you should bill for the time spent delivering services related to the covered complaint. Per Wallace, you should be careful to not overlap the services and “must think about each issue as two separate patients.” Additionally, your documentation should clearly justify the time spent working with the patient on each distinct issue.
So, there you have it: how to bill for physical therapy services on multiple body zones for the same session. And of course, if you have any questions, feel free to leave them in the comment section below, and we’ll do our best to find you an answer—come rain or shine!