Last week, WebPT’s trio of billing experts—Dr. Heidi Jannenga, PT, DPT, ATC/L, WebPT President and Co-founder; John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management; and Dianne Jewell, PT, DPT, PhD, WebPT Director of Clinical Practice, Outcomes, and Education—hosted a live open forum on physical therapy billing. Before the webinar, we challenged registrants to serve up their trickiest PT billing head-scratchers—and boy, did they deliver! We received literally hundreds of questions on everything from CPT codes and modifiers to patient collections and claim denials. There was no way we could tackle them all during our live event, so our team compiled the most commonly asked ones and organized them into the following FAQ. (Please note that all of the advice presented below is just that—advice. We always recommend consulting with a billing or legal expert who is familiar with the rules governing your specific location and payer relationships.) Don’t see the answer you’re looking for? Leave us your question in the comment section at the end of this post, and we’ll do our darndest to get you a response.

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KX, 59, and G Modifiers

What modifiers are required for rehab therapy claims?

There are numerous modifiers that apply to different rehab therapy billing scenarios, including modifier 59, the KX modifier, and the therapy modifiers (i.e, GP, GO, GN). In order to receive payment for a claim, you’ll need to affix all applicable modifiers. To learn more about common therapy billing modifiers, check out this blog post.

We’ve been getting a lot of modifier 59-related denials lately, particularly from BCBS (for example, when billing 97140 with 97530). Do you have any idea why this may be happening?

From what we understand, these modifier 59 issues stem from changes within BCBS's approval process. Some individuals have reported success after sending in the corresponding medical records (e.g., documentation) proving that the services in question were separate and distinct. Others have had success with using the new X modifiers instead of modifier 59. In both cases, it’s worth noting that the services rendered must meet the criteria for modifier 59 (or X modifier) use. You should never affix modifier 59 simply to ensure payment if the services were not truly separate and distinct. Check out this blog post to learn more about proper modifier 59 use.

Do 97039 and 97139 require the use of modifier 59?

According to the NCCI pair chart on this page, 97039 and 97139 form an edit pair with 97164 and 97168. Thus, if you perform these two services during the same episode of care separately and independently of one another, then you will need to affix modifier 59.

If I use modifier 59 on codes that don’t require it, will there be any negative repercussions?

Perhaps. Overuse of modifiers could trigger a negative response from the payer, including an audit. It could also skew the data payers use to establish future payment rates.

How do I track a patient’s progress toward the therapy threshold—and should our billing department communicate this information to our therapists?

For starters, you should be asking all new patients if they have received any therapy services at any time during the year as all PT, OT, and SLP services will apply to their threshold. To determine how close the patient is to reaching the threshold, you can safely assume $80 to $100 per visit.

Additionally, you can access this information through CMS in one of two ways:

  1. You can electronically view dollar amounts accrued toward the therapy limits on the ELGA or ELGB screens within the CWF (Common Working File) or on the HIQA screen for those providers who bill through fiscal intermediaries, or
  2. You can contact your Medicare contractor directly and request information regarding therapy services provided to a particular beneficiary. The amount accrued toward the financial limit is based on claim received date rather than the date of service. This is available via your MAC’s IVR system

You can also track your patients’ progress towards the threshold within WebPT. To learn how, check out our user guide.

In terms of communication, it’s always a good idea to keep everyone who is involved in a patient’s care on the same page. However, if the services being provided above the cap are still medically necessary, the therapist should continue to provide them as usual—with the KX modifier attached, of course.

What is the GP modifier?

As we explained here, GP, GO, and GN are therapy modifiers that designate the type of therapy being provided (PT, OT, or SLP, respectively). Many payers require use of a therapy modifier when billing a designated therapy code.

Medicare

What is the process for billing Medicare Advantage and Medicare replacement plans? Do we need to bill original Medicare first—or at all?

There’s still a lot of confusion around the way Medicare is organized. There are three broad areas:

  • Medicare Part A, which covers inpatient services;
  • Medicare Part B, which is covers services rendered as part of the physician fee schedule; and
  • Medicare Part C, which is otherwise known as Medicare Advantage.

Patients who are covered under Medicare can choose to sign up for Part C, which provides greater coverage for Part B services. The really critical thing that you have to do is check the patient’s Medicare card to determine whether he or she has Medicare Part B or C for outpatient coverage. Patients will have a separate card for their Medicare Advantage (Part C) plan. And that’s who to bill for the service. Typically, you have to be contracted with the Medicare Advantage Plan payer. If you bill original Medicare Part B, you’ll get a denial. For all Medicare Advantage plans, you’re billing just as you would bill a commercial payer.

Why is Medicare reducing reimbursement rates when I bill multiple charges?

Several years back, Medicare introduced a policy known as multiple procedure payment reduction (MPPR). In essence, this policy means that when a rehab therapist performs and bills for more than one related service during the same visit, Medicare will not pay the claim in full. To learn more about this reduction and how it may impact your reimbursements, refer to this blog post.

I know all 50 states offer some form of direct access, but doesn’t Medicare require a referral anyway?

There are no physician prescription or visit requirements under Medicare. However, in order to receive reimbursement for physical therapy services, you must demonstrate that the patient is under the care of a physician by obtaining a physician signature on the therapy plan of care (POC). This is where your physician networks can come in handy, as you can send patients to a PT-friendly physician to obtain certification. For more on Medicare’s plan of care requirements, refer to this blog post.

How does “incident to” billing work in PT? What would be considered fraud with “incident to” billing?

During the webinar, Wallace provided the following PT-relevant example of “incident to” billing for Medicare: if a PT is supervising a PTA, the PTA would bill under the PT’s NPI, as PTAs are not required to have NPIs.

According to Wallace, a fraudulent example of “incident to” billing would be a physical therapy tech performing a service and billing under the PT’s number. Now, if a PT works in a physician’s office, then the PT can treat in addition to the physician (i.e., “incident to”), or the PT can bill under his or her own NPI number (i.e., not “incident to”).

How should I bill when a Medicare patient has a secondary insurance?

As long as the services you are providing are medically necessary—and you document accordingly—you should continue billing Medicare as primary (and applying the KX modifier if the patient has exceeding the $2,010 threshold, as we explain here). If you can document that the services are medically necessary, you should keep going. A true secondary payer will adjudicate the claim after Medicare pays and may reimburse for services Medicare denies.

Will Medicare pay for services administered by a massage therapist?

No. You must be a licensed PT, OT, SLP, or therapist assistant to bill Medicare for services provided in a therapy practice.

If we provide treatment in a retirement community or assisted living facility, would the place of service be considered “home?”

Yes, because you’re technically providing those services in the patient’s home. Just make sure the patient is not also under the care of a home health agency—and if the patient was previously receiving home health care, verify that the patient has been discharged. In these types of settings, there’s often a nurse who comes in for routine services, like checking a patient’s blood pressure. In that case, the patient is receiving home health services; thus, you won’t receive payment for providing Part B services.

Are there ever limits on the number of units a PT can bill for a visit—for either Medicare or commercial insurance?

Sometimes, but not often. Be sure that you’re billing only for the services that you’re actually providing. And check the terms of your contracts with your payers—both commercial and Medicare.

How should we go about billing Medicare for maintenance program? Will Medicare pay for maintenance therapy?

Contrary to popular belief, Medicare will pay you to perform services under a maintenance program as long as you document that a therapist’s services were necessary to achieve the goal. So, carefully document why the skilled services of the therapist were medically necessary. We’d also recommend using outcomes tests on a continual basis to demonstrate that you’re preventing a further decline in function or slowing a decline in function that would otherwise occur if you weren’t providing maintenance therapy. To learn more about providing maintenance therapy under Medicare, refer to this blog post.

Should I issue an ABN as soon as a Medicare patient hits the $3,000 threshold?

You should never automatically issue an Advance Beneficiary Notice of Noncoverage (ABN) based on a patient’s total charges alone. Remember, there is no hard cap on therapy services, and Medicare will continue paying for services beyond both the $2,010 and $3,000 thresholds as long as those services are medically necessary and the provider affixes the KX modifier to the claim. The ABN comes into play when services are not medically necessary. For more information on the KX modifier, check out this blog post. To learn more about ABNs, refer to this article.

How should PTs go about billing Medicare for splints (orthosis)?

According to this resource from the American Society of Hand Therapists (ASHT), “Medicare covered orthoses must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.” You must be DME-certified with Medicare to bill directly for splints. Otherwise, you may bill for your professional time using the appropriate CPT codes and bill the patient for supplies or lab fees as a non-covered service.

What are NCDs and LCDs, and where can we find them?

As explained here, “NCDs (National Coverage Determinations) and LCDs (Local Coverage Determinations) are decisions by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary on certain services offered by participating providers.” You can find LCDs here and NCDs here.

If a physician doesn’t sign the POC within 30 days, can we have the patient sign an ABN and take financial responsibility for the cost of those services?

No. As Brooke Andrus explained in the comment section of this blog, “It is the provider's responsibility to obtain plan of care certification, so no, [we] would not recommend that you bill the patient. If you are unable to get a physician signature, then you won't be able to receive payment for the services you provide.” That being said, as Erica McDermott explains in the post itself, “The certifying provider doesn’t necessarily have to be the patient’s regular physician.” So, you may want to consider obtaining that signature from another eligible provider with whom you have a good relationship. Or, take your chances on filing a delayed certification, which Medicare may—or may not—accept.

How can I minimize the impact of MPPR on my billing?

Always bill for what you do. According to Wallace, “We don’t treat payers; we treat patients. Anything else is gaming the system and can set you up for a recovery audit.”

Can I bill Medicare for a progress note?

No. According to compliance expert Tom Ambury in the introduction to this blog post, “It is not appropriate to bill...when reporting ‘normal predictable progress’”—regardless of the timing or whether “a more thorough assessment is being performed.” That’s because Medicare “considers this to simply be a good documentation practice, and therefore it would not be payable under Medicare guidelines.”

How do we bill Medicare for an initial evaluation completed on a direct access patient? We receive denials when we do not include a referring provider on the claim.

Medicare should pay for an initial evaluation when that is the only service billed. As explained in this New Grad Physical Therapy article on treating direct access Medicare patients, “When billing for the evaluation, you can only bill the evaluation code; 97161, 97162, or 97163. If you bill other CPT codes during the evaluation, Medicare will deny them.”

Can an ATC bill Medicare or other third-party insurances?

As this resource from the American Athletic Trainer Association (NATA) states, “Athletic Trainers are not allowed to bill Medicare for services rendered to a Medicare beneficiary.” This is because CMS does not recognize ATCs as Medicare providers. While most commercial payers tend to follow Medicare’s guidelines, you should verify whether ATCs can bill for services with each payer individually.

How does the 8-minute rule work?

For an in-depth guide on the 8-minute rule, check out this WebPT resource.

Should we issue an ABN even if the patient is only responsible for a small dollar amount—like $5?

Yes. You should issue an ABN before providing services that the patient will be financially responsible for—regardless of the amount. Without an ABN on file, Medicare does not allow you to charge the patient.

How do we bill Medicare for co-treatment?

That depends on whether you’re billing Part A or Part B. We cover the ins and outs of co-treatment under Medicare in this blog post. Additionally, this can depend on what type of setting you’re in. This resource from the APTA lists the variations in co-treatment requirements between rehab therapy settings.

If we are not a Medicare DME provider but we have the patient sign an ABN for that item, do we still have to bill Medicare for the item?

Not according to this resource. Per the flow chart diagram, if you are not contracted as a Medicare DME supplier, then you should issue an ABN and collect payment from the patient directly.

Will Medicare reimburse for a massage code?

According to this Medicare page, “Medicare doesn’t cover massage therapy.”

How do you complete functional limitation reporting when a patient is being seen for one diagnosis but comes with a second?

Check out this resource on how to complete FLR with multiple plans of care.

Can I accept cash for services from a Medicare patient?

Check out this series of blogs to learn more about Medicare and cash-pay services.  

Other Rules and Regulations

Can we bill charges for a new therapist under an existing therapist if the new therapist is not credentialed yet?

Most commercial payers do not allow retro-certification, so you may not be able to recoup payment for services provided by a therapist who is awaiting credentialing. That being said, as Jannenga wrote here, “a credentialed therapist may co-sign the note if the co-signing therapist supervised the treatment the contractor or uncredentialed therapist provided. Similar to the rules dictating how to bill for a PTA, the credentialed therapist must provide direct onsite supervision (i.e., he or she can be in the same building but not necessarily in the same room) and must be immediately available to intervene (i.e., he or she cannot be doing something that is uninterruptable) in order to co-sign on the note.” And for Medicare, specifically, Jannenga explained that as long as the non-credentialed therapist’s “paperwork has been sent in and is pending CMS’s approval, the therapist can begin to treat patients. However, your practice must hold all billing claims for that new therapist...until he or she receives credentialing approval.”

We treat in a multidisciplinary practice. How do we bill for a patient seen by a PT and an OT on the same day?

Make sure that you’re using therapy modifiers to indicate the therapy type for a particular service. These modifiers include GO (for occupational therapy), GP (for physical therapy), and GN (for speech-language pathology). Now, while Medicare recognizes these modifiers, that’s not the case for all payers. And if a particular payer does not recognize them, the associated charges will likely be denied as duplicates. In this case, you may be able to call the payer to sort it out, but most tier-one support reps you talk to will not be able to help you. So, when you receive these types of denials, be sure to appeal them.

How many times a year is direct access able to be used by same patient?

There’s no limit to the number of times a patient can directly access physical therapy. However, some commercial payers do limit the number of initial evaluations they will pay for in a given time period.

What is the correct billing process for auto accident and workers’ comp patients? Do we have to wait for the case to be settled, or should we collect from the patient upfront?

Work-related injuries and auto accident injuries can have very different billing rules depending on the state in which you practice. Some states have no-fault provisions; others use PIP. Check with your state APTA chapter, private practice group, or attorney for information on letters of protection, liens, and other things that help to protect your ability to get paid in cases of litigation resulting from accidents or work-related injuries.

What if an auto accident or workers’ comp patient does not want to file with a third party and instead wants us to just bill their primary insurance? Is that allowed?

Yes, you are required on the 1500 form and the EDI-format equivalent to disclose if the injury was work-related or accident-related. The payer will then decide whether it will pay based on the insurance contract issued by the payer to the insured. Most payers employ coordination of benefits provisions in these cases. The payer will disclose them to you or your patient.

When a physician issues a prescription for PT, how long is that prescription valid (e.g., if the patient waits several weeks to schedule an initial evaluation)?

According to this resource, a physical therapy prescription “does not have an expiration date on it and the reason for which the prescription for physical therapy was written in the first place still applies, then you should be able to use it without problems.” However, we recommend reviewing the requirements for each one of your payers as well as your state practice act before treating a patient whose prescription is more than 30 days old.

How do we bill for services provided by a PTA?

We’ve covered PTA billing extensively in the past. To start, we recommend reviewing this blog post and this one.

If a patient has insurance but wants to pay cash, are we allowed to accept cash payment?

This situation is happening more and more as high-deductible health plans are becoming more prevalent. However, depending on the terms of your contract with that patient’s insurance company, accepting a cash payment could constitute a breach. So, it’s a good idea to review the terms of your insurance contracts and reach out to a healthcare attorney for further guidance.

Can PTs bill for telehealth services?

The answer to this depends on the payer. As of right now, PTs—as well as OTs and SLPs—cannot bill Medicare for telehealth services. Many commercial payers also will not reimburse rehab therapists for telehealth services. However, more and more payers are beginning to recognize the value of telehealth in the rehab therapy setting and will allow PTs to bill for telehealth. In short: Check with the individual payer. Additionally, you can track the Federation of State Boards of Physical Therapy’s telehealth efforts here.

How do we bill for fill-in or temporary therapists?

Here’s a resource to help you correctly bill for fill-ins and travel therapists.

If a patient leaves therapy for an extended period of time and then comes back, should we perform a re-evaluation or a new initial evaluation?

It depends on the circumstances surrounding the patient’s return as well as his or her insurance. Medicare, for example, automatically discharges patients after 60 days, meaning you’d perform an initial evaluation if a patient returned to therapy. If a patient returned before being discharged, you would either:

  • resume treatment (if the patient returned to treat the same issue and was at the same level of function as when he or she left therapy);
  • conduct a re-evaluation to adjust the plan of care (if the patient returned to treat the same issue but it was necessary to change the care plan); or
  • discharge the original case and conduct an initial evaluation to create a new plan of care (if the patient returned to treat a completely separate issue).

Can a chiropractor write a script for physical therapy?

Per CMS, “chiropractors and doctors of dental surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care."

What is the correct way to handle an overpayment by an insurance company, specifically one that we discovered on our own?

We wrote an entire blog post on this topic, which you can find here.

If we have encounters that have been open for more than five years, can we complete them and bill for them now?

That would depend entirely on the insurance company’s timely filing parameters, but it’s generally a good practice to bill immediately following an encounter.

How do we bill when a physical therapist assistant provides services to a patient?

Check out this resource to learn how to bill for assistants—and this one to ensure you’re remaining compliant with the supervision requirements.

What are the laws governing patient refunds?

To learn more about patient refund processes and legal considerations, check out this resource.

Revenue Cycle Management

What are ideal AR goals to shoot for? In other words, what percentage of AR should be at 0-90 days, 91-151 days, and 365-plus days?

While AR targets may vary by practice, here are some general targets:

  • 0 to 30 days: 50%
  • 31-60 days: 15%
  • 61-90 days: 8%
  • 90-plus days: under 30%

A simpler way to think about this is that 75-80% of AR should be under 60 days, and no more than 15-20% of AR should be over 90 days. That said, your 90-day percentage will largely depend on litigation for auto accident or workers’ compensation cases (some states are notoriously slow for workers’ comp).

What should our goal be for days in receivable outstanding (a.k.a. days sales outstanding or DSO)?

Depending on your state and payer mix, providers should aim for fewer than 35 days with a range of 20–40 days.

What is the point of having an RCM service? What all do they handle?

RCM services allow you to offload your billing to someone else rather than handling it yourself. Such services will take your patient information and charges and manage the claim submission process. They’ll also pass any unpaid services on to secondary payers. Some services also provide authorization and credentialing services. So, the question is, do you have the expertise and desire to effectively bill for your services and collect your own payments—especially considering that billing is becoming more and more challenging every year? If not, you should consider outsourcing. If you’re on the fence about outsourcing, you may find this quiz helpful.

How do you know what to charge a patient if you are unsure of that patient’s progress toward his or her deductible?

It’s critically important to get as much information as you can before the patient comes in for his or her first appointment. That means performing an extensive benefits check. Then, when the patient comes in, it’s important to ask the patient if he or she has had any procedures prior to coming to you—and to educate the patient on what a deductible is and how it may affect his or her financial responsibility. (If you’re looking for a tool to help educate your patients on the ins and outs of insurance, check out The PT Patient's Guide to Understanding Insurance.) If the patient recently had a major procedure, you can assume the deductible has been met. But, you should still collect any applicable copay or coinsurance. If the patient hasn’t had any procedures—or it’s beginning of the year—you should collect what you typically charge for that service. In the case of a high-deductible plan, your goal is to collect an amount that is as close as possible to what the patient will owe. Sometimes you might overestimate, and that’s okay. Just make sure you provide any refunds due to the patient in a timely manner. For tips on patient payment collections, check out this blog post; for advice on overcoming patient excuses for why they can’t pay, read this post.

What are your recommendations for collecting deductible, copay, and coinsurance amounts upfront? What if a patient can’t afford upfront payment? Should we see him or her anyway?

For tips on how to collect patient payments upfront—as well as what to do when a patient can’t pay—check out this blog post.

What is the best way to ensure our front-office personnel receive all the information they need during eligibility verification calls without spending too much time on the phone?

Eligibility verification can be time-consuming; however, it might help speed things up to establish a checklist that outlines all the information your therapists need to capture during their phone conversations with the insurance rep, including information about the patient’s financial responsibility (e.g., co-pay, coinsurance, and deductible) as well as therapy coverage:

  • number of visits that are covered,
  • the visit time frame,
  • the number of visits that have already been used, and
  • whether or not PT benefits are combined with other services such as OT or chiropractic care.

As Jannenga mentioned during the webinar, you’ll also want to be sure to verify the mailing address so you’re sending your claims to the right location.

Is there a benchmark for copay/coinsurance collection as a percent of revenue?

You should be collecting 100% of copays at the time of service. Realistically, coinsurance and patient balances should generally be under 15% of your total accounts receivable.

How should we go about setting our fee schedule?

It depends on your practice model as well as your region. As we explain in this post, insurance-based practices will want to set fee schedule amounts slightly higher than the allowable amounts for each payer. For cash-based practices, calculate “your gross income goal, divide that by the number of weeks you plan to work in a year, factoring in vacation and personal leave. The number you get is your weekly gross income. Then, divide that amount by the number of patients you can realistically see in a week.” The resulting amount is what the average out-of-pocket cost for your patients should be per visit. This number—as well as factoring in the types of services you provide on a regular basis—will give you a good jumping-off point for pinpointing your ideal service rates.

Is there a way to identify the largest commercial insurance providers in our area?

A Google search would be your best bet. However, according to this resource, these are the top five largest health insurance payers in the US:

  1. Unitedhealthcare
  2. Anthem
  3. Aetna
  4. Humana
  5. Cigna

CPT Codes  

When should we bill for an evaluation versus a re-evaluation?

First off, it’s important to understand that you should never bill a re-evaluation for a routine progress note. If you do bill for a re-eval, you are indicating there’s been some kind of significant change with respect to the patient’s progress and, therefore, his or her plan of care (POC). In fact, you should only bill for a re-evaluation if one of the following situations apply:

  • Through your own clinical assessment, you note a significant improvement, decline, or change in the patient’s condition or functional status that was not anticipated in the POC for that interval.
  • You uncover new clinical findings during the course of treatment that are somewhat related to the original treating condition (i.e., a new diagnosis to add to the POC).
  • The patient fails to respond to the treatment outlined in the current POC, and you determine that a change to the POC is necessary.
  • You treat a patient with a chronic condition and you don’t see him or her for treatment very often.
  • Your state practice act requires re-evaluations at specific time intervals.

For more information on the difference between evaluations and re-evaluations, check out this blog post.

Are there limits to the number of evaluations you can bill for a patient within a particular time frame? Is there a way around being denied reimbursement for subsequent evaluations?

Some insurance companies may limit the number of evaluations they will pay for in a given time period. Please review the terms of your contract with each individual payer to learn the limits.

How should PTs bill for dry needling? Why is there so much inconsistency in how PTs are currently billing for dry needling?  

Part of the problem with billing for dry needling is that there’s not consistency among payers as to whether or not they cover it. Another part of the problem is that there’s a lot of conflicting advice on this issue from professional organizations. None of the usual physical therapy codes include dry needling in their definitions. So, some practitioners have asked if they should use the manual therapy code (e.g., 97140), and the answer to that is no, because the definition of that code does not include dry needling—even if the intent may be to address soft tissue (similar to manual therapy intent). However, we do recommend using the unlisted procedure code (97139). The unlisted physical medicine code (97799) is another possibility, but it often is not included on the fee schedule for PT services. You should check your contracts to verify.

Can therapists ever bill for documentation time?

You can include documentation time as part of your billable time as long as you are documenting while the patient is still with you (see tips for point-of-care documentation here). You would simply include this time as part of whatever service you were providing at the time you were documenting. So you cannot, for example, finish up your documentation at lunchtime for a patient you treated at 10:00 AM—and then add that time to the claim for that visit. Now, keep in mind that the evaluation code, in particular, is an untimed code. So, it is meant to include everything associated with an evaluation (e.g., history, assessment, and treatment planning). But, because it’s untimed, there’s no need to bill for documentation time associated with the evaluation.

Do you always have to bill for group therapy when you see more than one patient during the same time period?  

That depends on what type of service you’re providing and how long you interact with each individual patient. As this CMS resource states, “Group therapy consists of simultaneous treatment to two or more patients who may or may not be doing the same activities. If the therapist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, it is appropriate to bill each patient one unit of group therapy.” Conversely, one-on-one time is time-based, and billing a one-on-one code implies the provider gave constant attendance to the patient for interventions for a cumulative total of 8 minutes or more—which means they fall under the 8-minute rule.

Can you charge a patient cash for a service that does not have a CPT code?

That would depend on the specific service performed as well as the relationship that you have with that patient’s insurance company. To learn more about providing and billing for cash-based services, check out this blog post and this one.

What documentation is required for use of CPT 97112 other than the time statement?

This CPT code denotes neuromuscular re-education. You can learn more about what kind of treatment falls under this description by reviewing this page. Your documentation for this—or any other type of service—should clearly demonstrate that the treatment provided meets the code description.

During the webinar, John Wallace mentioned that we should bill for administration and management time. What code should we use for that?

Assessment and management time is a component of provider work for a service represented by a CPT code and, as such, is included in the time you allot to the CPT code. For example, let’s say you performed manual therapy on a patient’s frozen shoulder. The total time for the service is 25 minutes. During that time, you asked the patient how he or she did after the last treatment and whether he or she had pain sleeping on that side. You checked accessory joint motion of the shoulder; palpated the rotator cuff and bicepital groove; performed long-axis traction, grade ii-iv GH joint distraction, posterior glides grade ii - iv, and soft tissue mobilization to the subscapularis insertion. You then finished by re-checking accessory movement and AROM and PROM. The correct code and charges would be two units of 97140 representing both the hands-on time and the assessment and management time.

What is the correct CPT code for pelvic floor training?

As with all treatment interventions, you should use CPT codes whose definitions most accurately reflect the intent for your treatment. So, depending on what you are trying to accomplish, any of the movement intervention codes (97110, 97112, or 97530) may be appropriate. If you have the proper equipment, 90911 may also be appropriate.

Are there certain CPT codes that indicate medical necessity (e.g., hands-on codes)?

Your documentation should support the medical necessity of your services—regardless of the services you provide or codes you use. That is in addition to demonstrating that the services can only be performed by a licensed rehab therapist.

How should we bill for lymphedema treatment?

As explained here, it depends on the type of therapy being provided as well as the patient’s insurance. Depending on those two factors, “use 97535 to instruct on performance of compression and garment instruction in addition to therapeutic billing.” Additionally, “Compression CPT codes 29581-29584...are per-treatment codes that you should bill with one unit. If you perform compression during the same session as manual therapy, append a 59 modifier to the 97140 CPT.”

What is the difference between therapeutic exercise and therapeutic activities? Is it better to bill one or the other?

According to this resource from DCAligned, therapeutic activity (CPT code 97110) “is a therapeutic procedure, on one or more areas, each lasting 15 minutes. Therapeutic exercises are performed in either an active, active-assisted or passive (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening) approach.” Therapeutic activities are activities intended to improve functional performance (e.g. sitting, bending, carrying, reaching, etc.). Therapeutic exercise, on the other hand, refers to exercises that target strengthening, endurance, range of motion, and flexibility.

What is the expected payment for 97039?

According to Rick Gawenda in the comments of this post, it’s at the insurance carrier’s discretion whether or not they pay for a service such as 97039—as well as what they pay.

ICD-10 Codes

We are starting to receive more and more referrals that have "opioid dependence" or "long-term drug therapy" listed as the top diagnosis. Other diagnoses will be things like abnormality of gait or muscle weakness. Since we are seeing an increase in opioid dependence as a diagnosis, what are your thoughts about physical therapists including this on claims as an underlying diagnosis?

Obviously, we here at WebPT are hugely supportive of the movement to leverage rehab therapy as an alternative to prescription medication. This represents a huge opportunity for the rehab therapy profession—one that could eventually lead to physicians sending patients to rehab therapists before prescribing opioids or other painkillers. One of the rallying cries behind the transition to ICD-10 was that this code set allows for greater specificity in diagnosis coding—and that means including as many codes as necessary to fully describe a patient’s situation. With that in mind, we recommend including the code for the opioid dependence as well as the codes for the resulting conditions that are at the heart of what you’re specifically addressing. To learn more about using multiple ICD-10 codes on a single claim, check out this blog post.

When adding ICD-10 codes to a claim, does the order matter?

It can. As we explain in this resource, in the notes section of the Tabular List, “you'll find directives such as ‘Use additional code’ or ‘Code first’ (‘Code first’ indicates you should code the underlying condition first).”

Denials

We keep getting CO16 denials, which means the claim lacks required information. But, we are having a hard time figuring out what is missing. What should we do?

As explained in this article, “When a CO16 denial is received, the first place to start is by looking at any accompanying remark codes. These remark codes are there to further define what information is missing.” The article goes on to detail several common remark codes. This AAPC forum provides additional advice on CO16 denials.

What do you do when you’ve exhausted all your rights in terms of appealing a denial, and you know beyond a shadow of a doubt that you did not receive the correct payment? Is my only option to write off the uncollected amount?

Almost all commercial payers—as well as Medicare—have defined appeals processes with different levels of appeals. Most people give up at the first level, but you should be willing to go to the third level, because that’s where the provider usually wins. If you write a good letter pointing to why your claim should be paid—and you can clearly show how your documentation justifies that—then you should be able to successfully get that claim paid.

What are your best tips to minimize claims coming back denied or rejected?

For tips on ensuring clean claims and first-pay payment, check out this blog post.

Can you explain the Medicare denial code CO59? It appears to reduce the reimbursement rate when multiple charges are billed concurrently. However, I can't figure out how they calculate the deduction or pinpoint the codes that are more affected.

CO59 is an MPPR remark code. As explained in this CMS resource, this code is intended to make payment adjustments easier to recognize on remittance advices. For more information on MPPR, check out this WebPT blog post.

Are we receiving denials because our therapists do not add modifier 59 or any other modifiers (except G-codes) to their claims?

Perhaps. If your therapists are performing services that form edit pairs independently and separately of one another without affixing modifier 59 to the appropriate code, then that may very well be the reason for the denial. To learn more about modifier 59, check out this blog post.


Wowza—that’s a whole lot of billing Q&A. As mentioned in the intro of this post, we’re happy to take a crack at any remaining brainbusters you may have. Simply leave ’em for us in the comment section below.

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