Healthcare billing is a bit of a beast—but you already know that. Between navigating the ICD-10 code book, the CPT codebook with all of its HCPCS codes, and the plethora of billing rules put forth by CMS and other payers, it’s tough to create clean claims. But learning the twists and turns of labyrinth-like billing is a necessity to running a successful clinic, which is why we thought it could be helpful to provide you, not with misplaced modifier examples, but with some correctly modified billing scenarios. Read through the following treatment scenarios, and decide how to apply the different physical therapy modifiers that most often apply to rehab therapists. You can choose from the following:
1. The Scenario
A patient with patellofemoral pain seeks treatment. At the beginning of the patient’s appointment, the clinic PTA provides 13 minutes of therapeutic exercise (CPT 97110), after which the PT provides manual therapy (CPT 97140) for 22 minutes. Then the PT leads the patient through 15 more minutes of therapeutic exercise.
Every claim submitted by a PT, OT, or SLP requires a therapy modifier (GP, GO, GN). Since these services were provided by a PT, affix the GP modifier to the claim. Because a therapy assistant contributed to this care, the physical therapist assistant modifier (CQ) also comes into play (per CMS’s 2022 proposed rule). Generally speaking, the therapy assistant modifiers apply when a therapy assistant provides more than 10% of a service (though of course there are some exceptions to this rule that you can explore here). In this scenario, apply the CQ modifier to one of the two units of 97110. However, we will have to wait until CMS’s final rule comes out in November to determine if this will be allowed in 2022.
- 97140: GP
- 97110 (1 unit): GP
- 97110 (1 unit): GP, CQ
2. The Scenario
After recovering from a broken arm, a Medicare patient develops adhesive capsulitis of the shoulder and seeks treatment from a PT. During one of their treatment sessions, the PT provides manual therapy (CPT 97140) before asking the patient to complete some therapeutic activities (CPT 97530) like reaching up and lifting light-weight objects to eye-level. After that, the PT works with the patient on improving ADLs (CPT 97535), including holding the arm in an elevated position during simulated teeth-brushing and opening and shutting overhead cabinets.
To round out the session, the therapist provides dry needling (CPT 20560) in the affected area. Since Medicare doesn’t cover dry needling, the therapist issues a voluntary ABN.
Since these services were provided by a PT who is submitting this claim under their name, affix GP to the claim. Next, take a look at the services provided. CPT codes 97530 and 97535 form an NCCI edit pair. Since they were provided as separate and distinct services, they can both be billed—but one service line will require a 59 modifier. Finally, since the therapist issued a voluntary ABN for the dry needling (and since dry needling is a statutorily non-covered service), affix the GX modifier to the claim line with the 20560 CPT code.
- 97140: GP
- 97530: GP, 59
- 97535: GP
- 20560: GP, GX
3. The Scenario
A Medicare patient receives a left total hip arthroplasty via a posterior approach and seeks post-op care from a physical therapist with a goal to discontinue the use of a straight cane with ambulation. The PT begins today’s treatment with 9 minutes of one-on-one neuromuscular education (CPT 97112), before asking the onsite PTA to oversee the final six minutes of exercises while they briefly step away. The PT returns to furnish the patient with gait training (CPT 97116) and provide a follow-up walk test and Lower Extremity Functional Scale (LEFS) survey (CPT 97750).
After the conclusion of the treatment session and while finishing up their documentation, the PT realizes that the patient has exceeded their annual therapy threshold.
Let’s start with the therapy modifier. Since these services were provided by a PT who is submitting this claim under their name, affix GP to the claim. Next, let’s look at the contributions of the PTA. Remember that when more than 10% of a service is provided by a therapy assistant, the service line requires a modifier. Since the PTA provided more than 10% of the neuromuscular reeducation service, apply the CQ modifier to that unit.
Finally, remember that the patient has exceeded their annual therapy threshold. Since their treatment was medically necessary, affix the KX modifier to the claim and bill Medicare as normal.
- 97112: GP, CQ, KX
- 97116: GP, KX
- 97750: GP, KX
4. The Scenario
A Medicare beneficiary with Ehlers-Danlos syndrome is seeing an occupational therapist to help manage their joint hyper-mobilization. Recently they purchased a wheelchair (per their physician’s recommendation), which the OT plans to help train them on. During the first appointment with the wheelchair, the OT performs neuromuscular reeducation (97112) for 10 minutes, and then the OT and COTA provide wheelchair training (CPT 97542) in tandem for 11 minutes. The OT steps away, and the COTA provides 12 more minutes of wheelchair training.
At the end of the appointment, the patient requests manual therapy (CPT 97140) to temporarily soothe their pain. The OT agrees, though they note that they don’t believe the manual therapy is medically necessary and ask the patient to sign an ABN.
Because these services were provided by an OT who is submitting this claim under their name, affix GO to the claim. Then, consider the services administered by the COTA. The COTA individually provided 12 of the 23 minutes of wheelchair training, meaning one of the two units of 97542 will require the CO modifier. (Once again, the ability to do this will depend on CMS making these changes final in its 2022 regulations.) Finally, because the OT does not believe the manual therapy was medically necessary and because they obtained a signed ABN, affix the GA modifier to the service.
- 97112: GO
- 97542 (1 unit): GO
- 97542 (1 unit): GO, CO
- 97542: GO, GA
5. The Scenario
A Medicare beneficiary is seeing a PT for a case of upper-cervical neck pain that they believe is triggering major headaches. They mention at the beginning of their appointment that they think they’ve surpassed their therapy threshold. The PT proceeds with the appointment and provides joint and soft tissue mobilization for the cervical spine (CPT 97140) before providing the patient with instruction in ergonomic and postural adaptations (CPT 97537). Finally, the PT performs dry needling to the affected area (CPT 20560), but does not collect an ABN.
Since this treatment was provided by a PT and the claim will be billed under their name, affix GP to the claim form. Because the patient has surpassed the annual therapy threshold, affix the KX modifier to the services that Medicare will pay for (i.e., 97140 and 97537). Finally, because dry needling is a statutorily uncovered service and the PT did not collect an ABN, affix the GY modifier to 20560.
- 97140: GP, KX
- 97537: GP, KX
- 20560: GY
Avoiding denials may feel like a herculean feat, but it’s one that’s totally within the realm of possibility. By knowing rehab therapy billing rules like the back of your hand (or by partnering with someone who remembers them for you), you too can become a clean claims champion.