We once again opened the floodgates to your compliance questions during our latest billing Q&A webinar, and you didn’t disappoint. Dr. Heidi Jannenga and John Wallace went deep on compliance and hopefully left viewers better educated on how to properly code, bill, and document for those treatment cases that fall outside the everyday. In case you missed it, we’re going through everything we covered during that session — which you can also catch on the video replay.

Therapist credentialing

We started with a brief discussion of therapist credentialing, an often-misunderstood topic. 

For Medicare:

• Once providers have completed their 855-I personal provider application in PECOS, they can charge for services as of the date of their application. If they’re already a provider and awaiting reassignment of payment to a practice’s TIN, they can charge beginning on the date of their request for reassignment. 
• However, this doesn’t mean that the practice can start filing those claims straight away; to stay compliant, they need to hold those claims until the enrollment notification comes through, at which point they can forward those claims to the MAC for retroactive payment. 
• For providers working in a hospital setting, there’s nothing to sweat; billing is done at the facility NPI level rather than individual NPIs.
• One important note: Do not look to circumvent these rules by having an enrolled therapist co-sign claims alongside the therapist awaiting enrollment or reassignment.  

For commercial payers/workers’ comp: 

• You’re billing for care under a provider’s NPI and the practice’s TIN
• Payer policies may vary on retroactive reimbursement for services rendered during the enrollment/reassignemnt process, so check with each one before charging for services. 
• It’s rare that private payer policy permits co-signature for unenrolled therapists with an enrolled therapist, so trying that puts your practice at risk.
• The “panel full” problem: If you’re having trouble enrolling another therapist, the payer may have closed the network to limit coverage in the area. If your new therapist is replacing one who left your practice, ask for them to drop the previous provider and add the new one.  
• Once again, do not try to circumvent enrollment rules by having an enrolled provider co-sign for an unenrolled provider. Therapists can’t work incident to another therapist.

Therapist coverage

From there, we moved on to therapist coverage—a related topic that generates as many questions and compliance concerns. 

For Medicare:

• Like enrollment, therapists covering for another provider need to complete the payment reassignment section of the 855-I form in PECOS, and those claims must be held until enrollment is confirmed, at which point the MAC will reimburse retroactively. Of note: therapists can have more than one reassignment in place because payment is tied to a practice’s TIN. 
• Similarly, coverage and reassignment aren’t a concern in ORFs/hopsitals due to facility NPI billing.
• A temporary substitute provider under “locum tenens” is only permissible for practices located in Healthcare Professional Shortage Areas (HPSAs), Medically Underserved Areas (MUAs), and Rural areas as designated by HHS. 

For commercial payers/workers’s comp: 

• Each payer likely has its own policy, which can vary greatly from other payers. You’ll have to do some research before using substitute providers
• Having an enrolled provider co-sign a claim with an unenrolled provider is generally not acceptable unless detailed otherwise in the payer’s policies 

Q&A

The bulk of the session was taken up with the question and answer period. As always, there were too many for even our esteemed and experienced pairing to get through, so as always, John Wallace has taken the remaining questions and written out his responses below.  

ICD-10

Can you go over the new ICD-10 changes with exclusion criteria?

In ICD‑10‑CM, exclusion criteria are formal instructional notes printed in the Tabular List. They tell coders when two diagnoses cannot or can be reported together. These rules are binding and part of the ICD‑10‑CM Official Guidelines.

Types of Exclusion Notes

1. Excludes1 — “NOT CODED HERE” (Mutually Exclusive)

• Indicates that the listed condition cannot occur at the same time as the code it appears under.
• Never report the two codes together.
• Represents conditions that are clinically incompatible (e.g., Type 1 vs. Type 2 diabetes).
• Violating Excludes1 results in claim denials.
  

Examples:

• E11 (Type 2 diabetes) has an Excludes1 for E10 (Type 1 diabetes).
• Acute vs. chronic versions of the same condition.
• Congenital vs. acquired forms of a condition.
  

2. Excludes2 — “NOT INCLUDED HERE” (Coexisting Allowed)

• Means the excluded condition is not part of the code’s definition.
• The patient may have both conditions, and both codes may be reported if documented.
• Indicates related but distinct conditions.

Why Exclusion Notes Matter

• Prevent contradictory or redundant coding.
• Ensure accurate clinical representation.
• Avoid claim denials and audit findings.
  

What can you tell us about the new SLP CPT codes for 2027?  Can they be provided virtually?

See the CPT Manual or https://www.asha.org/practice/reimbursement/coding/slpcpt/  (the 2027 updates have not been updated yet, but will be, I’m sure.

Coding

Can you go into more detail with the difficulty walking and unsteadiness on feet codes?

You cannot bill R26.3 with R28.81.

Is there still a CPT code for Maintenance Therapy?

No, Maintenance Care uses the regular CPT codes, and documentation (outcome measures) must show function is not decreasing as quickly as much as would be expected from the patient’s condition.

In your opinion, should therapists continue to bill 20560/20561 Dry Needling to Medicare with an ABN on file for advocacy of fee-scheduled payment needed? Is it required for therapists to bill this service to Medicare, or can the charge always be self-pay?

Medicare does not pay for dry needling. An ABN is not required. It should always be documented as cash pay.

I’d like to know about billing diversification. Are there additional codes we should be utilizing for services that we may already be providing and billing differently?     

Your documentation must show how interventions are changing based on the patient’s response to treatment, whether that is adding additional interventions, discontinuing others, or changing intervention dosage.

I am a hand therapist, and my organization is not a DME provider. I’m always looking for input on the best codes for billing for splints and fabrication without being a DME provider!

Bill your professional services of assessing the patient for a device and fitting the device. The patient must pay for splinting supplies and fabrication time.

Modifiers

With Modifier 96 (habilitation), do we still collect any copays, co-insurance, deductibles, etc.? 

Yes.

When billing 97112, 97530, and 97750 on a date of service, is it appropriate to add the 59 modifier to the 97750? 

With 97750 and 97140, the -59 mod goes  97750.  97112 and 97539 are not edited with 97750.

Are modifiers XE/59 interchangeable with most payers? Are you finding payers prefer one over the other? 

No. For therapy services, only use the -59 mod.

Why are we getting ERAs back that do not have copays, deductibles, etc., when we've used modifier 96? 

It may be the plan for that particular payer or government program. Are you sure you aren’t referring to the remark code/CARC code 96, which means services weren’t covered?

We have a patient who gets manual therapy and traction.  Humana Advantage (PEEHIP for retired teachers) is denying the Manual Therapy even with a 59 modifier. Is there another modifier we can use to get paid for both? 

No, Humana is using an old edition of the NCCI.

Do you need to add a GA modifier to patients who had home health and may not be discharged in time for outpatient therapy? 

No, and ABN does not permit you to bill a patient covered under an HHA Plan of Care.

When billing for OT and SLP visits for the same patient on the same day, which charge should the modifier 59 be added to, and should these visits be billed together or separately? 

All services should be billed on the same claim with the appropriate discipline-specific G modifier and the NCCI edits applied.

Billing

Can a therapist co-sign a PTA's treatment if they are not in that particular facility?

In the 2025 Final Rule, CMS lowered the requirement for PTA supervision from direct supervision to general supervision, with the caveat that state practice acts supersede CMS’ rules. Similarly, Medicare does not require a therapist to co-sign a PTA’s daily note, but payers and state practice acts might require it. You need to check both your state practice acts and payer guidelines to see what the standard is.    

How do you bill a non-covered service, such as wellness or maintenance after discharge, separately from covered care?

Covered services would be billed to the payer; non-covered services would come out of pocket from patients. For Medicare patients, you can have them sign an ABN for good measure. 

For lymphedema treatment: when is it appropriate to bill 29584 and 97140?

PT 29584 is used for the application of multiple layers of compression bandages to the arm or hand. This procedure is more complex than a single-layer compression and is typically performed to reduce swelling, support the extremity, and manage conditions like lymphedema during the intensive decongestive phase of therapy. The procedure requires layered materials applied in a specific sequence to generate graduated compression, which helps control fluid accumulation and promotes healing. You should always check to see if the payer has an online published lymphedema management policy and then follow those guidelines.

What is the best way to get reimbursed for vestibular rehab?  I use ICD-10 code 95992, but it only covers 15 min, and often the procedure takes longer than 15 min if performing more than 1 repetition to fully resolve.  Can I put the remainder of the time in ther ex 97110 or manual 97140?

95992 is an untimed code, so it covers the number of canalith repositioning maneuvers necessary. Any other balance interventions should be billed using 97112.

Good Faith Estimate: If I understand correctly, this is for patients who do not have insurance/are electing to be "self-pay" at my practice.  At my practice, we charge a flat rate for self-pay; for example, $100 per visit.  On the GFE, do we still need to list out all of the CPT codes?

The APTA has a handy guide to Good Faith Estimates that breaks down the required elements as per CMS standards, including: 

• A description of the primary service or item — what’s being furnished based on the patient’s initial reason for the visit. Use clear and understandable language, and, if applicable, include the scheduled date it’s being provided.
• An itemized list of any additional services or items, grouped by each provider or facility, that you reasonably expect to be furnished along with the primary service or item.
• The applicable diagnosis codes, expected service codes, and expected charges associated with each listed service or item.

How are L Codes billed? Since they’re not in the PT/OT LCD, do they just go on the claim? Are GO/GP modifiers assigned?

L codes are billed to the MACs that process DME, not the Part B MACs. The provider modifiers are not used.

If a Physical Therapist co-signs a note with a PTA, do those minutes go under the PT? 

If treatment was provided by a PTA, those minutes would still be assigned to the supervising therapist or therapist responsible for the POC. 

Credentialing

When multiple therapists will provide care to a patient during their plan of care (e.g., at the clinic, Therapist A and Therapist B might provide care, and occasionally Therapist C will float in and provide care), do we have to do locum tenens / PECOS / MAC updates?For reference, billing is on 1500, and Therapists A, B, and C are all credentialed with the providers and under that tax ID.  

All therapists treating the patient must be credentialed.

Should travel PTs get credentialed? Even if only in the clinic for 13 weeks?

Yes.

PTAs

On the PTA question….if the supervising Therapist is an hourly employee and off the clock or not working, can they still supervise the PTA at that time?

For Medicare, PTA supervision is general, so as long as the therapist is available, the assistant is covered. Be sure that you are in compliance with your state’s supervision requirements, as they may be different.

Can a therapist co-sign a PTA's treatment if they are not in that particular facility?

Co-signing implies direct supervision, so the therapist should be present.

Compliance

What is best practice when completing Pre-Op and Post-op Assessments for Total Joints? Should you schedule, complete, and bill for two evaluations with the second one having a z code for post operative procedure or should you bill one evaluation and one re-evaluation?

Make the decision whether to bill for an evaluation vs. a re-evaluation based on the patient’s condition and any health or functional changes since the first evaluation.

Our old director told us that we can not bill TA with Medicaid patients. Is this true?

No.

We do a Good Faith Estimate for the patient to sign for all Dry Needling billed to Medicare.  Did you say we have to do a separate note from their other services?

That depends on your software. Many times, software will require a different case for when payment changes from Medicare to Cash.

If we have an agreement with an insurance plan, can the patient choose to do self-pay and not bill insurance?

No.

Is a plan of care still required to be signed by a physician on all insurance? 

You should check your payers’ policies as some do require a signed POC.

So if a patient is Medicare, they don't need a referral? Or is that still per state?

Medicare does not require a referral for direct access patients, but Medicare does require a physician-signed POC.

Worker’s Comp

Do federal worker's comp patients also follow other federal insurances (ie. Medicare) guidelines regarding use of non-licensed staff? 

Generally, yes.

Medicare: When a patient has an open or prior workers’ comp case, Medicare often flags claims for completely unrelated injuries as workers’ comp, even when the workers’ comp-related box is marked “No.”  What’s the best way to handle these claims and get them processed correctly?

The patient must contact the Medicare Coordination of Benefits office and take care of resolving the other claims.

Our clinic is newer to WebPT Billing. We’ve had some issues with billing modifiers for DME and telehealth. We used Therabill previously and when we select the same place of service and modifiers that we’ve used in Therabill, we are getting denials or rejections in WebPT Billing for incorrect modifiers/ place of service. Could you speak to the proper way to set up these items to be billed correctly?

You should contact WebPT Support.

We are adding FCE's to our service line. Any suggestions on billing for Functional Capacity Evaluations?

Unless instructed otherwise by the payer, bill the FCE in 15-minute increments using 97750.

Do rehab agencies and other institutional settings need to be DMEPOS providers to bill for DME, orthotics, and prosthetics?

No. Outpatient Rehabilitation Facilities (ORFs) and other institutional providers do not need to be registered as DMEPOS suppliers to bill for DME, orthotics, and prosthetics under Medicare Part B, provided they meet the institutional and billing requirements in 42 CFR 410.38 and the Medicare Claims Processing Manual.

Does Medicare allow 4 units per visit, or can I bill 5?

Medicare does not have a regulatory limit on the number of units billed in a visit. Regardless of the number billed, your documentation must support the medical necessity of the billed charges.

If we have an agreement with an insurance plan, can the patient choose to do self-pay and not bill insurance?

No.