Earlier this week, Heidi Jannenga, PT, DPT, ATC—WebPT’s Co-Founder and Chief Clinical Officer—and John Wallace, WebPT’s Chief Business Development Officer of Revenue Cycle Management, paired up to answer rehab therapists’ most burning billing questions during a live Q&A-style webinar. And, boy, did we get a lot of great ones. So many, in fact, that we couldn’t possibly get to them all live, so we created this massive post-webinar post (our biggest yet) with the most commonly asked questions—and their answers. Use the link bank below to jump to the section that interests you most, or start from the top and make your way all the way through. (Don’t see an answer to your exact question? Check out our billing blogs for more.)
CPT and ICD-10 Codes
Does it matter what order our ICD-10 codes are listed on our claims?
As we explain here, when you submit more than one ICD-10 code per service line, “it’s crucial that you list the codes according to importance, with the first-listed (i.e., primary) code being the one that most strongly supports the medical necessity of your services. In many cases, that means coding for causation first and foremost.”
Does it matter what order our CPT codes are listed on our claims?
Typically, no. Most payers reimburse based on the relative value units (RVUs).
What are the best physical therapy CPT codes in terms of reimbursement? Should we target billing a certain number of units?
As Jannenga explained during the webinar, you can’t pick and choose which billing codes you want to use based on how much they pay. To bill for a service, you have to actually perform it. And you should only perform services that are relevant to a patient’s plan of care and progress. However, it’s important to know when you can use a higher-reimbursed code. TherEx is often used as an all-encompassing code, and that’s probably why it’s a lower-paying code. So, understand the differences between codes (e.g., TherEx versus Therapeutic Activities versus Neuromuscular Re-education), and know when it’s appropriate to bill one over the other. To learn more about maximizing your billing through better coding, check out this blog post.
Do ICD-10 codes impact billing payout? What about insurance type?
The short answer is yes—diagnosis codes can impact reimbursements. However, it’s difficult to say how much—and with which codes—because payment rates and guidelines vary so much from payer to payer. That being said, based on this article, there’s an observed correlation between code specificity and reimbursement amount, which makes sense considering that one of the drivers of the ICD-10 transition was that the new code set affords greater coding detail.
What CPT code should I use to bill for cupping or kinesiology taping?
Some providers have reported success with billing for cupping using CPT code 97139 (Unlisted Therapeutic Procedure). However, some payers may not cover this service.
What CPT code is most appropriate for billing patient education?
In most cases, you will bill for education using the code that is most relevant to the education being provided. For a more detailed explanation, refer to this blog post.
Is 97039 a billable CPT code?
According to Rick Gawenda of Gawenda Seminars, CPT code 97039 would be appropriate for services including “low level laser, cold light, low light laser, a chair that provides heat, massage, and traction all at the same time, mechanical massage therapy, and equipment and tables utilizing roller systems…” For more information check out his post on the differences between 97039, 97139, and 97799.
When and how do we use 96112 and 96113?
According to this ASHA resource, 96112 indicates “developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed)...with interpretation and report; first hour.” 96113 is an add-on code for “each additional 30 minutes (List separately in addition to code for primary procedure.)”
Is there an appropriate code for a routine progress note?
Nope. There is no specific code to bill for a progress note. However, if you performed a physical performance test or assessment for the minimum number of minutes, you can bill CPT code 97750 as well as the CPT codes for any other treatments you rendered.
What is the best way to bill for dry needling?
Billing for dry needling is definitely tough, because—for now—it doesn’t have its own CPT code, and many payers have differing dry needling policies. As Wallace mentioned during the webinar, he recommends providers use the unlisted procedure code (97139) with proper documentation to support the medical necessity of dry needling. The good news is that CMS has introduced two new dry needling-specific CPT codes that it hopes to put into effect in 2020. We will know the fee schedule when the final rule is released at the end of the year.
When is it appropriate to bill therapeutic activity? What about neuromuscular education?
Bill for therapeutic activities (97530) when performing exercises that are related to functional, real-life activities (e.g., carrying, lifting, throwing, squatting, or crawling). Neuromuscular re-education (97112) is marked by feedback and guidance back to the patient about the quality of movement. It also includes balance and body mechanics training, balance activities, proprioception training, and desensitization. For more information on what to bill when, check out this blog post from Meredith Castin about what to bill when.
How does Part A billing differ from Part B billing for rehab therapists?
We’ve written an entire post on that topic, which you can find here.
Is it acceptable for our billing office to send Medicare claims without a plan of care signed by a physician?
Yes, you can submit a claim prior to receiving a physician’s signature on the plan of care. However, you must attempt to obtain the signature within 30 days of the date of service. If you do not receive a physician’s signature within the timeframe, you must—at the very least—be able to prove that you have made reasonable attempts to do so.
What information needs to be on a Medicare certification and recertification?
According to Chapter 15 of the Medicare Benefit Policy Manual, “The format of all certifications and recertifications and the method by which they are obtained is determined by the individual facility and/or practitioner.” CMS considers the following documents acceptable documentation of certification:
- Progress note
- Referral or order
- Plan of care that has been signed and dated by a physician or non-physician provider
Furthermore, the signed plan of care must indicate that “the physician/NPP is aware that therapy service is or was in progress and the physician/NPP makes no record of disagreement with the plan when there is evidence the plan was sent.”
How do you bill for beneficiaries who have Medicare as a secondary payer?
Medicare has a fact sheet to help providers understand how to bill properly when a patient has Medicare as a secondary insurance. As Wallace mentioned on the webinar, providers must submit the EOB from the primary payer to Medicare.
What advice do you have for a therapist who is under manual review?
Comply with Medicare’s requests in a timely manner. As long as your documentation is defensible and supports the medical necessity of your services, it should be a fairly straightforward process.
What are TPE audits?
As we explained here, according to CMS, Targeted Probe and Educate (TPE) audits are “designed to help providers and suppliers reduce claim denials and appeals through one-on-one help.” As explained here, probe audits target:
- “providers and suppliers who have high claim error rates or unusual billing practices, and
- “items and services that have high national error rates and are a financial risk to Medicare.”
When is it appropriate to issue an ABN?
As we explain here, “you should only have a patient sign an ABN when you’re providing services that you know are:
- not covered by Medicare, or
- not medically necessary.”
Here are several specific situations when it is not appropriate to issue an ABN:
- After receiving a denial from Medicare (you can never issue an ABN “after the fact”; it must be provided before the service is delivered);
- Anytime a patient exceeds the KX modifier threshold or targeted medical review threshold (if continued treatment is medically necessary, you should apply the KX modifier and continue to bill Medicare; you should only issue an ABN if continued treatment is not medically necessary);
- When you would prefer to collect cash for covered services rather than bill Medicare (even if the patient is willing to pay cash, you cannot accept it; you must bill Medicare for all covered services);
- When providing maintenance therapy (Medicare covers maintenance therapy and does not require patient improvement as a condition of payment);
- In any routine capacity (Medicare strictly forbids providers from issuing “blanket” ABNs to guarantee payment no matter what);
- When you are unable to obtain a signed plan of care within 30 days (even if you made a legitimate attempt to obtain a physician signature); and
- When billing Medicare Advantage rather than Original Medicare.
What does this statement mean under the MIPS low-volume threshold criteria? “Provide ≤ 200 covered professional services under the Physician Fee Schedule (PFS).”
A professional service, according to CMS, is "one professional claim line with positive allowed charges." So, essentially, CMS is counting the number of billable codes on each claim—not the number of billable units. Once you've billed 200 billable codes to Medicare, then you've satisfied that particular criterion of the low-volume threshold. If you're interested in learning more about MIPS, I definitely recommend checking out this webinar and this guide.
What services can I provide to Medicare beneficiaries if I don’t participate in Medicare?
Rehab therapists who have no relationship with Medicare may still provide wellness services to Medicare beneficiaries on a cash-pay basis.
Do we still have to use the codes and modifiers associated with functional limitation reporting?
No. Staring January 1, 2019, functional limitation reporting ceased to exist, and providers no longer have to report FLR G-codes and severity modifiers for Medicare claims.
If a patient has both Medicare and Medicaid, can we collect the Medicare deductible?
Technically, this depends on your state's Medicaid rules, but in most cases, the answer is no.
Why do I need to complete a progress note every 10 visits, even though FLR is gone?
Despite the fact that Medicare no longer requires functional limitation reporting (FLR), CMS has not indicated that the 10-visit rule disappeared along with it. Because of this, we strongly recommend providers continue completing a progress note every 10 visits in order to ensure Medicare compliance.
Under what conditions is it appropriate to bill Medicare for a re-evaluation—or discharge a patient and perform a new evaluation?
WebPT’s Kylie McKee wrote an entire blog post that explains this in detail. Check it out here.
For Medicare patients, can we bill a CPT code for a service or intervention prior to billing an evaluation code?
For Medicare patients, you must begin every episode of care with an initial evaluation in order to establish a care plan.
This is our understanding of Medicare: every tenth visit requires a reevaluation, and at the end of the POC or every 90 days (whichever comes first), we must get a new physician signature, and—if therapy is to continue—a new POC. How do people keep track of this?
- “An evaluation of the patient’s progress”;
- A professional judgement about continuing care;
- Modified goals and/or treatments—if necessary; and
- A discharge notice—if necessary.
Secondly, you don’t necessarily need to create a brand new plan of care every 90 days—you simply need to recertify the current POC. However, “if the patient’s condition changes in such a way that the therapist must revise long-term goals,” then you may want to create a new POC.
As for tracking all of these compliance requirements, some documentation software (like WebPT) will do all this for you. The WebPT EMR includes certification and signature status reports, and it allows users to attach physician signatures to the POC via eDoc.
If a Medicare patient has already exceeded the cap before arriving at my office, should I affix the KX modifier to the initial evaluation?
No; initial evaluations do not apply to the therapy cap, so you would not need to affix the KX modifier until you provide a medically necessary treatment.
A Medicare patient came in for an evaluation. The physician who wrote the patient’s PT referral no longer works at the physician's office, and none of the other doctors are willing to sign the initial plan of care. The patient hasn’t had a chance to find a new PCP yet—so, are we allowed to directly bill the patient for the evaluation?
We strongly advise against billing the patient directly. If the initial evaluation happened fairly recently, you may still have some time to get a signature on the original plan of care. As we write here, "to remain in compliance with this condition of payment, a therapist must obtain a signed plan of care certification within 30 days of a Medicare patient’s initial therapy visit." So, assuming 30 days haven't passed, you may still begin treating the patient, and he or she can take the time to get scheduled with a new PCP and grab a signature.
If I treat a Medicare patient twice on one date of service on two different body regions, can I still bill Medicare and get paid?
Yep. Here’s some advice from our Medicare Open Forum that explains how to handle this situation: “When treating a patient for two separate diagnoses on the same day, you'll need to combine these services onto one claim. Furthermore, if more than one therapist is treating the patient on this date of service, both therapists' treatments would have to be on the same claim… Now, 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.”
Can we still get paid for Part B services if a patient is receiving home health services?
No. Medicare will not reimburse for Part B services if a patient is under the care of a home health agency billing Part A. So, as we explain here, anytime you begin seeing a Medicare patient, “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.”
If a Medicare patient tells us that he or she isn’t in home health and we treat the patient without getting an ABN—only to discover later that the patient actually is receiving home health services—can we bill the patient when the claim is denied or recouped?
Unfortunately, there’s not much you can do. You could try to appeal to Medicare, but there’s no guarantee they will reply favorably.
When seeing Medicare patients, do we have to record the patient’s check-in and check-out time, or is it sufficient to just document the total direct treatment time?
As Wallace explained during the webinar, the time in/time out requirement disappeared some time ago. But, you must record the total treatment time, and you also need to show the number of minutes for each timed CPT code.
Can clinics get reimbursed for interpretive services? Is this a cost that we have to absorb as a clinic or is there a way to get reimbursed?
While this may vary by payer, with respect to Medicare, “There is no Medicare benefit for foreign interpreter services.” (See more details here.) If the payer does not cover the service, you may be able to charge the patient. Please note that while workers' compensation often covers interpretive services, you likely will need to obtain authorization.
What’s the best practice for finding out if a patient is receiving Part A services (e.g., SNF or home health services)?
The very best practice to determine if your patients are receiving concurrent care under Medicare Part A is to ask your patients if they are receiving care from any other provider—and what the details of that care are.
Can we bill Medicare for discharge?
A discharge note is essentially a type of progress note. As such, you cannot bill for it. Instead, you would bill for the services rendered during the patient’s final visit.
Why are we seeing reduced reimbursements when we bill more than one unit of a particular code?
This could be due to Medicare’s multiple procedure payment reduction (MPPR). As we explain here, “rehab therapists who perform more than one ‘always therapy service’ on a patient during the same visit see a 50% cut to the practice expense (PE) that he or she bills to Medicare.”
How can I take advantage of direct access with Medicare patients? Doesn’t Medicare require a physician referral?
Nope. Medicare does not require a physician referral. However, you must obtain a physician’s signature on the plan of care in order to receive reimbursement for physical therapy services. As we mentioned in our last billing FAQ, “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 information on Medicare’s plan of care requirements, check out this blog post.
Will you please explain which Medicare regulations also apply to Medicare Advantage?
While MA plans are funded by Medicare, questions about coverage, out-of-pocket costs, billing, and referrals are unique to the providing company. When in doubt about a particular Medicare Advantage plan requirement, reach out to the payer directly before providing services to the beneficiary. We actually wrote a blog post on that topic here.
What is Medicare’s definition of medical necessity? How do I know whether a service is medically necessary?
According to this blog post, “Per Medicare, for covered services to be considered medically necessary, they must:
- Be safe and effective;
- Have a duration and frequency that are appropriate based on standard practices for the diagnosis or treatment;
- Meet the medical needs of the patient; and
- Require a therapist’s skill.”
However, as WebPT’s Erica McDermott explains here, “What Medicare considers ‘reasonable and necessary’ isn’t always cut and dried; instead, it varies based on on both National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). And it’s up to you to know the current NCDs and LCDs that govern your practice. To start, you can download the Medicare NCD Manual here and use the search tool here to identify the LCDs associated with your geographic region.”
Telehealth physical therapy is a non-covered Medicare service, so should we treat it like a wellness service, ditch the ABN, and charge cash?
Yes, the patient can pay cash. But you’ll want to make sure the patient understands that the service is not covered under Medicare. And while ABNs are not mandatory when providing non-covered services, you can choose to provide one on a voluntary basis—and that might not be a bad idea.
Also, make sure you can use the telehealth codes in your state and, if so, verify any rules surrounding telehealth (e.g., what types of devices you can use). Finally, make sure the patient understands how you charge for telehealth services and what the service entails.
Will Medicare reimburse physical therapists for the new remote patient monitoring telehealth codes (e.g., 99453, 99457, and 99454)?
Where can we learn more about Medicare billing rules?
Medicare is probably the most communicative payer when it comes to providing education around billing and compliance rules and regulations (although, that education admittedly is not always the easiest to understand). The CMS website has a host of resources to help providers get up to speed—and we do our best to translate some of the most important Medicare rules here.
If a patient has exceeded the therapy threshold and we receive a denial (even though we applied the KX modifier), what can we do? Can we continue treating the patient?
If Medicare denied services that exceed the therapy threshold, it’s likely because the services did not appear to be medically necessary. If you believe the services do fit Medicare’s definition of medical necessity (and your documentation supports that), you can file an appeal. If the denial stands, you can continue treating the patient. However, he or she must complete an Advance Beneficiary Notice of Noncoverage (ABN) to indicate that he or she accepts financial responsibility.
Should you continue using the GP modifier even after meeting the $2,040 amount and applying the KX modifier?
Yes. Medicare still requires that providers use the GP modifier for services provided under a physical therapy POC—even after applying the KX modifier.
Can we start applying the KX modifier before the patient actually exceeds the threshold?
As soon as you become aware that a patient will likely exceed the therapy threshold (i.e., the soft cap), you should ensure that your documentation supports the continued medical necessity of your services. However, we recommend waiting to apply the KX modifier until the patient gets as close as possible to the cap without exceeding it. Using the KX modifier too early could be a potential red flag and may put you at greater risk for an audit. For more information on proper use of the KX modifier, refer to this blog post.
How do we calculate a patient’s progress toward the KX threshold?
First of all, keep in mind that the KX threshold (i.e., the therapy soft cap) is based on the allowed amount—not the billed or collected amount. (The same is true for the secondary targeted review threshold.) As we explain here, “To calculate the patient's ‘running total’ toward the therapy threshold, you can reference the allowable fee schedule. In the event that the patient can't provide you with a history of the therapy services he or she has received, you can request this information from CMS by contacting your Medicare contractor.”
If we go way over the threshold, are we at a higher risk of audit?
According to Wallace, nationally, 20-35% of practices go above threshold, and he hasn’t seen any increased audit activity in practices that often exceed the KX threshold or the targeted review threshold. That being said, if the vast majority of your patients—say, 90%—are going over the thresholds, there’s a good chance CMS may ask for some for your charts. But, try not to stress. Medicare doesn’t automatically recoup money, and this type of review can be a good learning experience. Typically, the worst case scenario is that CMS will recoup partial reimbursements and explain what you did incorrectly so you don’t make that mistake again in the future.
Does the therapy threshold apply to Medicare Advantage plans?
Nope. The threshold only applies to patients under Medicare Part B.
Do home health services count toward the cap?
The therapy threshold (i.e., the soft cap) accounts for Part B therapy services only. Thus, any Part A services delivered via a home health agency would not count toward the threshold. However, services provided in a patient’s home as part of an outpatient plan of care—and billed under Part B—would count toward the threshold.
When will Medicare do away with the therapy cap? Will we still need to use the KX modifier after this?
Medicare has already repealed the therapy cap; however, there is still a threshold in place beyond which therapists must affix the KX modifier. You can learn more about this process here.
If the billing office delays in submitting claims to Medicare and we discover some claims should’ve had the KX modifier applied, do we need to go back and correct those claims and add the KX?
Yes. Regardless of the current amount billed at the time, if the claim should’ve had the KX modifier applied, you will need to addend the claim before submitting.
What is the best way to track a Medicare patient’s progress toward the KX threshold?
First, be sure to ask each new patient whether he or she has seen any therapy providers since the beginning of the plan year. Then, get an estimate of how many visits the patient attended. As we explain here, “To determine how close the patient is to reaching the threshold, you can safely assume $80 to $100 per visit.”
You can also obtain this information from CMS by:
- Electronically viewing “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
- Contacting your Medicare contractor directly and “requesting 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.”
If you’re a WebPT Member, you can track progress toward the therapy threshold within our application. Check out this user guide to learn more.
Why do most insurances reimburse when 97140 and 97530 are billed together with the 59 modifier applied—but others (like Aetna and Humana) do not?
While most payers adhere to Medicare’s NCCI edit list and requirements for modifier 59 use, some payers have their own rules. To that end, we’d recommend reaching out to Aetna and Humana to identify how they would like you to proceed.
Can I also us modifier 59 to perform services on different body zones?
As Meredith Castin explained here, modifier 59 is also appropriate when you perform a procedure on a separate and distinct body part. That said, in some cases, for some payers, it might be more appropriate to us the XS modifier to indicate that the service was distinct because it was performed on a different structure or organ.
One of Ohio’s Medicaid plans, Buckeye Health, won’t pay when we bill 97140 and 97530 together—even if we include modifier 59. Why is this?
It’s tough to say for certain since many payers (even Medicaid payers) enforce unique billing rules. That said, this document from Ohio’s Department of Medicaid explicitly states that Ohio Medicaid programs recognize the XE, XP, XS, and XU modifiers—all of which act as alternatives to modifier 59. It’s possible that you may need to swap out your 59 for an appropriate X modifier. Additionally, someone in this AAPC coding forum suggested that the payers may simply want additional documentation that supports the use of the modifier. In any case, your best bet is to contact the payer and ask what’s happening.
We are dealing with several insurance companies that automatically deny any claim that includes modifier 59. Are insurance companies allowed to deny a claim outright because it has a 59 modifier? Should I be billing an X modifier instead?
According to the American Academy of Professional Coders (AAPC), “Unfortunately, modifier 59 gets misused a lot. As a result, some payers now automatically deny CPT® codes appended with modifier 59. This forces the provider to appeal the denial and send in the documentation to show that modifier 59 was applied correctly.” So, the short answer is yes. Sometimes payers do deny claims that contain modifier 59 outright.
The best way to head this issue off at the pass is to:
- Look through our NCCI edit pair chart and ensure that you’re affixing modifier 59 to the correct codes;
- Contact your payers to see if they would prefer you use an X modifier; and
- Document defensibly—and have that documentation ready to give to payers.
Do services have to last a full 15 minutes in order for us to apply modifier 59 on a claim?
All timed services should follow the 8-minute rule (or the rule of eights)—regardless of the modifiers affixed to them.
How do we know which column the modifier goes in?
As of July 1, 2019, you can apply the modifier to either column.
Can I apply the 59 modifier to all CPT codes on my claim?
No. You should only apply Modifier 59 to codes that form edit pairs.
If I receive a denial when using the 59 modifier, can I replace it with an X modifier?
This depends on whether or not the payer accept the X modifier. Check with the payer first before doing so.
Where can I find more information on correct use of the 59 modifier?
The WebPT Blog is a really good place to start. If you’re wondering which codes are eligible for 59 modifier use—and how to determine whether modifier 59 is appropriate in any given billing scenario—check out this post, this one, this one, and this one.
Can you use the X modifiers with the 59 modifier? Does it have to be in a particular order?
Generally speaking, you would use either an X modifier or the 59 modifier—not both. That being said, the rules of X modifier and 59 modifier use are not consistent for all payers. If you are experiencing denials related to these modifiers, we recommend contacting the payer for additional clarification and guidance and/or submitting an appeal.
What are the GP, GO, and GN modifiers?
GP, GO, and GN are therapy modifiers that designate the type of therapy being provided (PT, OT, or SLP, respectively). Many payers—including Medicare—require that providers use a therapy modifier when billing a designated therapy code. If in doubt, reach out to the payer directly.
Can you clarify billing “always therapy” and “sometimes therapy” codes—particularly when those services are provided by therapy practitioners versus non-therapy practitioners?
According to this CMS resource, all outpatient therapy (OPT) services furnished by therapists in private practice are “always considered therapy services, regardless of whether they are designated as ‘always therapy’ or ‘sometimes therapy.’ As such, the appropriate therapy modifier must be included on the claim. However, it may be clinically appropriate for physicians and NPPs to furnish OPT services that have been designated ‘sometimes therapy’ codes outside a therapy plan of care—in these cases, therapy modifiers are not required and claims may be processed without them.”
How are the CO and CQ modifiers different from the UB and U5 modifiers?
CO and CQ modifiers are specific to Medicare and indicate outpatient physical or occupational therapy delivered in whole or in part by a physical therapist assistant (PTA) or occupational therapy assistant (OTA), although some commercial payers may adopt them as well. With that in mind, it’s best to verify with each of your commercial payers which modifiers they require.
Are the CQ and CO modifiers needed for offices that bill as a facility?
CQ and CO modifiers are required for all outpatient physical therapy services that are provided either in full or in part by a PTA or OTA.
Is there a modifier I can use to stop or lower the impact of sequestration?
No. Sequestration went into effect in 2013, and it will remain in effect until further notice.
Do you still have to use GP modifier when using the CQ modifier?
Yes. Per the APTA, the new therapist assistant modifiers—CO for OTAs and CQ for PTAs—should be appended “on the same line of service as the respective PT, OT, or SLP therapy modifiers (GP, GO, GN).” To learn more about these modifiers, check out our post on the 2019 final rule.
Is there a resource to find out what modifiers need to be used with each CPT code for each insurance company?
Unfortunately, there isn’t one all-encompassing resource. However, resources like the APTA and the WebPT Blog provide a lot of information on modifier use.
Is modifier 25 appropriate to use for physical therapists?
As WebPT’s Kylie Mckee explains here, “providers should only ever use modifier 25 in conjunction with an E/M code—specifically, those within the range of 99201-99499. Because it’s highly unusual for rehab therapists to submit E/M codes, they generally should not use modifier 25. But, should you ever need to use modifier 25, you must ensure your documentation supports it completely.”
Have you heard about the use of modifier 96 and 97 with Humana claims?
According to compliance expert Rick Gawenda of Gawenda Seminars, for some insurance providers, modifiers 96 and 97 replaced the SZ modifiers to indicate whether a service was habilitative or rehabilitative, respectively.
Orthotics, DME, and Prosthetics
When I bill for a pair of custom-made orthotics, should I bill one unit of L3020, or two units with LT and RT modifiers?
According to Noridian, if you’re billing the same items or accessories “on the same date of service, and the items are being used bilaterally,” then you should bill two units of L3020 on two separate claim lines. One of the claim lines should include the LT modifier, and the other RT.
Do I have to become a DME provider to collect payment for my custom splints?
There are specific requirements you must satisfy in order to receive payment for splints, prosthetics, and orthotics. Learn more here.
I’m having issues with denials from certain insurance companies when rendering treatment and orthotics/splints on the same date of service. Any idea why this is happening?
Per this AOTA resource, “Private insurance may have differing policies and a separate claims address for DMEPOS claims. Check with the insurance carrier for their specific DMEPOS policy.”
How should we bill for orthotics and prosthetics?
We’ve written an entire blog post on this topic. Check it out here.
Evaluations and Reevaluations
Can you clarify the correct procedure for billing evaluations? Should we bill for the entire time it takes to complete an evaluation (from chart review to locating equipment), or should we only bill for the skilled evaluation itself? Should hands-on time that isn’t considered testing receive an additional treatment code?
Evaluations are considered untimed services, which means you should always bill one unit—regardless of how long it took to complete. This unit covers all elements of the evaluation, including history, examination, plan of care development, and all assessment activities. Any treatment delivered during the initial evaluation visit should be billed separately using the appropriate codes. Keep in mind that you cannot bill for other assessment activities the same day that you bill for an evaluation.
Do payers actually reimburse for re-evaluations?
Yes, but only when billing for a re-eval is warranted. For some examples of when it’s appropriate to bill for a re-eval, check out this post from the WebPT Blog.
If a current patient gets new insurance during an episode of care, be it commercial or Medicare, is it necessary to perform a new evaluation?
Generally speaking, unless the patient requires a new evaluation because he or she presents with another condition or diagnosis, you would not provide or charge for a new evaluation (unless, of course, the payer requires that for payment). To that end, it’s best to check with the new payer. Finally, if Medicare is the new insurance, you would need to establish and certify a plan of care, which may warrant an initial evaluation.
Can I use 97110 in a group therapy setting?
No. This is a one-on-one code. That being said, you can bill for one-on-one services provided to individual patients who are part of a group as long as your delivery of the service meets the definition for one-on-one treatment. Learn more here.
When you have multiple patients in the clinic at the same time, how do you juggle your time so you can appropriately bill one-on-one CPT codes? We do not have techs or aides.
To successfully provide one-on-one care in a group setting, you must divvy up your treatment time into “notable episodes.” In other words, you must spend enough one-on-one time with a patient to provide skilled treatment—though you can pinball between them and another patient and add up the total time later. To learn more, check out these two articles:
- One-on-One Services vs. Group Services
- How to Bill for One-on-One Therapy Services Provided in a Group Treatment Setting
Is it possible to bill a constant attendance code in a group setting? For example, say you’re treating two patients simultaneously. The first patient is receiving manual therapy, and the second is performing exercises. You teach the second patient some exercises, and then step away and perform manual therapy on the first patient—but you continue to observe and correct the form of the second patient. In this situation, can you charge 97140 for the first patient and 97110 for the second patient?
Yes! You simply have to provide your service to the patients in notable episodes (CMS defines this as a five-minute intervals)—and you can’t double bill minutes. So, for example, if you treat two patients over the course of an hour, the number of billed units (i.e., minutes) can’t exceed 60 minutes. Take a look at these two articles to learn more about billing one-on-one services in group settings:
- One-on-One Services vs. Group Services
- How to Bill for One-on-One Therapy Services Provided in a Group Treatment Setting
How do you negotiate fee schedules with insurance companies?
First, determine your cost of doing business, because you’ll need that to prove the need for a higher reimbursement rate. Also, before you make the call, determine whether you’re willing to walk away from the contract. Many people start out by taking what they can get, but if it’s not worth hanging onto (i.e., the amount you receive doesn’t cover your costs), be prepared to let it go. Then, communicate with your referral sources.
And while we’re on the topic of knowing your costs, it’s important to stay on top of those numbers because they’ll help you identify when it’s time to renegotiate or drop a contract.
How do you handle payers that only pay a fixed amount—no matter what you do?
Depending on the situation—especially, if what the payer reimburses is less than the cost to provide the services—you may want to consider going out of network with that payer (assuming, of course, that you’ve negotiated to no avail). We discuss when it’s time to drop a payer in this blog post.
KPIs and Benchmarking
Where can we find some general billing and A/R benchmarks?
How do we calculate cost per visit to determine if we should remain in-network with a particular payer?
As we explained here, you’ll want to “consider everything that goes into treating your patients and running your business each day—including rent, technology systems, payroll, supplies, and insurance. Divide this number by the number of patients you typically see during the course of each day. This is your net cost per visit.”
What is the average number of units per hour worked in an outpatient setting?
As we explained here, “According to this resource from the American Academy of Orthopaedic Surgeons, the average PT visit takes 45 to 60 minutes, which results in charges for about three and a half (3.5) weighted procedures (WPs) or one and a half (1.5) work relative value units (RVUs). Typically, 3.5 WPs per visit translates into three timed procedures and one modality.”
What is a good target for A/R over 120 days?
As we explained here, aim for less than 10% of your account receivables to be over 120 days.
Credentialing and Contracting
If you have a non-credentialed therapist whose application being processed by Medicare, can you have a credentialed therapist co-sign the note, or should you be holding those claims until credentialing goes through?
As we explain here, “A therapist can begin treating patients—even if he or she is not yet officially Medicare credentialed—as long as the Medicare credentialing paperwork is pending CMS’s approval. However, the practice must hold all billing claims for that therapist (up to one year from the date of service, per timely filing rules) until the credentialing approval comes through.”
Where can I learn more about provider credentialing?
In-Network vs. Out-of-Network
How can we help out-of-network patients obtain reimbursement from their insurance companies?
In order for patients to receive reimbursement directly from their insurance company for your services, you’ll need to provide them with a superbill that shows all the information—including the CPT codes—that you would otherwise submit directly to the insurer. For this reason—and others—we recommend that even cash-pay practices use an electronic medical record to ensure that bills and documentation are accurate and defensible. Plus, even if you’re out of network with insurance payers, most state practice acts still require your documentation to fully supports the care you provided.
What is the best language to use with a patient when he or she has an insurance you don’t take?
Ultimately, the most important thing to convey when communicating that you are out of network with a patient’s insurance is that being out of network enables you to provide better care for that patient. By communicating the value of your services, you are more likely to have buy-in from a patient to (potentially) pay more out of pocket to receive, say, more individualized care. That said, depending on your policy, you can also share that you provide superbills that will enable the patient to receive reimbursement directly from his or her insurance company. Finally, in some cases—especially for patients with high deductible health plans—your out-of-network charges may actually be less than what that patient would pay via copays and coinsurance. If that is the case, it’s an important thing to highlight.
When billing a patient that is out of network, can you charge the patient more than the allowable in-network rates?
Barring any specific state laws, out-of-network providers can charge whatever the market will support in their location. However, as we explain here, “Insurance companies reimburse patients according to their own fee schedules, and each insurance company has a ‘different rate of reimbursement for different codes.’ It’s important to remember that ‘as a provider, you do not have control over what the insurance reimburses, only over what you bill/receive as payment from the patient,’ [Ann] Wendel said.” The article went on to recommend that, when figuring out what to charge, you consider “‘overhead costs, caseload size, and clinic location’ as well as ‘the amount of income you need to generate to live on and keep your practice running smoothly.’ Charging anything less than that could be bad for business.”
Is it possible to bill in-network with some payers and out-of-network with others?
It certainly is. You can maintain contracts with your preferred payers and go out-of-network with the others. To learn more about going out of network, check out this webinar.
What is the best way to handle patient with a Medicaid plan when you are out-of-network? Can the patient pay cash or are we obligated to refer him or her to an in-network provider?
Because Medicaid is a state-run program, the rules will vary from state to state. We recommend reaching out to your state’s Medicaid agency to verify.
Assistants, Aides, and Students
Can a PTA bill for services under the direct supervision of a licensed MD, or only a licensed PT?
PTAs may only perform services under the supervision of a licensed PT.
Thank you for the info about Tricare and PTAs. Does this also apply to patients with VA coverage?
The Department of Veterans Affairs (VA) Veterans Health Administration (VHA) covers only veterans—those who are retired and meet certain criteria or who have served in the military but are no longer active duty. Patients accessing VA therapy services can be treated by PTAs.
Have PTAs officially been added to Tricare’s coverage policy? I’ve found numerous articles from the last year discussing the possibility of this happening, but I cannot find confirmation that the process is complete.
As far as we know, the comment period for this policy change ended earlier this year, but it has not yet gone into effect. Per our compliance officer, we're hoping the change will be effective next spring. We anticipate more information coming out as we get closer to the end of the year. In the meantime, I recommend checking out this post from the WebPT Blog for additional details.
If the PT signs the PTA’s note to indicate he or she supervised the service, do we still need to attach the CQ modifier? Will we still receive the reduced reimbursement?
Yes. The reimbursement reduction applies for all outpatient physical or occupational therapy services that were provided either in full or in part by a PTA or OTA. In this case, you would still affix the CQ modifier to the claim.
Can PT students input charges as long as a PT co-signs the note?
Students can enter documentation and billing information into the relevant software/note/claim; however, the licensed therapist must always review this information, as indicated by cosignature. Furthermore, there are very specific rules around student provision of services as well as billing for student-provided services. For a detailed explanation of student therapist supervision and billing rules, check out the “Therapy Students” section of this blog post.
What is the percentage of reimbursement reduction we can expect on PTA and COTA services?
Beginning in 2022, Medicare will reimburse services rendered by a PTA or COTA at 85% the usual fee schedule amount.
Is a PTA allowed to complete a progress note?
Medicare requires that licensed therapists complete all evaluative notes. For other payers, it’s best to check with them directly.
How does the billing process for PTAs differ from PTs?
We actually wrote an entire post on this for the WebPT Blog, which you can read here.
Denials and Appeals
If we receive a claim denial due to lack of prior authorization, can we keep the copay that the patient already paid?
As WebPT’s Erica McDermott explains here, that depends on the patient’s insurance plan: “If the patient seeks services listed as not covered in his or her plan benefits, he or she will likely end up receiving the bill for those services. However, if a provider fails to obtain the necessary preauthorization for a potentially covered service, he or she may be responsible for the cost—or the insurance carrier may assign financial responsibility to the patient. In the latter case, the provider would then have to choose between billing the patient or writing off the cost.” If the provider is responsible for the cost, then he or she would most likely need to refund any patient payments collected.
What source would you recommend for understanding denial codes?
For Medicare review codes and statements, check out this resource.
If a payer denies a claim as a result of the patient maxing out his or her benefits, how can we ensure we get paid?
This is exactly why we encourage providers to verify patient eligibility prior to a patient’s first session—and at least monthly thereafter. To determine if you have any recourse in this situation, review your contract with the payer.
What can I do if I received a denial because the date on the claim was incorrect?
In most cases, you can file for an appeal—as long as you can prove what the actual date of service was to the payer.
What are the next steps if all levels of appeal have been upheld but the payer isn't adhering to its contract?
If you feel your appeal has been unjustly denied or that the payer has broken the terms of your contract, you might wish to file a complaint with your state’s insurance commissioner.
What does it mean when we are getting denials for medical necessity?
In short, this means that the payer does not believe that the services you provided were medically necessary for that patient. If you’ve documented otherwise, you can submit an appeal including your defensible documentation for the payer to review.
Can incomplete documentation lead to denials?
Insurance companies commonly deny claims as a result of providers not creating defensible documentation that clearly conveys the medical necessity of the services they provide. Check out this defensible documentation toolkit to learn more.
General Rules and Regulations
When it comes to the 8-minute rule, would you recommend that providers record the exact number of minutes spent one-on-one with their patients, or just round up to the amount needed to bill a unit?
Definitely avoid rounding up the amount of time you spend completing a service for a patient. You want your documentation and billing to be as accurate as possible, and rounding up to get paid for a service could get you into some hot water. Ideally, you should try to record the exact number of minutes you spent completing a service for a patient—and use the 8-minute rule from there. If you're unsure exactly how many minutes you spent completing a service, you should make your best (and most accurate!) estimate.
We have had trouble getting any insurance companies to reimburse for progress notes and discharge notes. They are time-consuming to complete, so is there any way to obtain reimbursement?
Unfortunately, no. As we explain here, while progress notes and discharge notes are considered a good documentation practice—and progress notes are a Medicare requirement—therapists cannot bill for the time they spend creating those notes.
Does the 10-visit rule apply to workers’ compensation insurance?
That likely depends on the payer. However, the 10-visit rule is typically thought of as a Medicare-specific rule, and you will not need to adhere to it for most payers.
Is it ever okay to bill a patient privately if the patient has insurance? What would those circumstances look like?
That’s tricky—and will ultimately depend on the contract between you and the insurance company.
Why can chiropractors use therapy codes and claim that they are doing the procedures themselves, even if they don’t have a PT in their practice?
The GP modifier is intended to designate that a service is specifically a therapy service—not that it was necessarily provided by a licensed PT, OT, or SLP provider. This helps Medicare keep track of different metrics, like Medicare patients’ therapy cap progress, for example.
What are the legal obligations and regulations for returning patient overpayments? Are there any specifications that dictate how quickly these overpayments need to be returned to the patient?
Generally speaking, it’s a best practice to return patient overpayments as soon as you identify the overpayment. However, each payer may have a specific timeline outlined in your payer contract. To that end, it’s best to check with each individual payer. To learn more about patient refunds, check out this blog post.
What are the number of units allowed to be billed by state? We deal mostly with NY, NJ and CA. We've always thought it was four all around, but recently one of our payers we can’t bill more than three.
As far as we know, the number of allowable units is based on the payer rules—not the state’s. You should confirm the total allowable units with each payer you contract with.
How do I find out the state-specific workers’ compensation rules that apply to me?
As WebPT’s Kylie McKee explains here, “every state has a workers’ compensation commision that can answer questions and guide you on next steps whenever you hit a bump in the WC road—whether you need to balance unpaid workers' compensation claims or obtain interpreter services. Additionally, the Workers' Compensation Research Institute (WCRI) has two publications that make it easy to compare the various workers’ compensation laws among states: Managed Care and Medical Cost Containment in Workers' Compensation: A National Inventory and Benchmarks for Designing Workers' Compensation Medical Fee Schedules. You can also find additional information on workers’ comp laws on the US Department of Labor website.”
Can massage therapists bill commercial insurance carriers?
Some payers do reimburse massage therapy services. However, massage therapists can only bill insurance carriers if they're credentialed with the payer themselves. If a massage therapist isn't credentialed with a payer, then he or she can only provide cash-pay services. We recommend that massage therapists check in with the massage practice board if they are interested in insurance credentialing.
Is it legal to charge a higher rate to cover credit card processing fees?
That depends on your state laws. We'd recommend checking with your state's Consumer Protection Agency, which you can find here.
Is it safe to keep credit cards on patient accounts?
It’s against the law unless you use a third party that is Payment Card Industry (PCI) certified. If you’re a WebPT Member, you can use our Integrated Payments tool to accept payment directly within the patient chart. Payments are tokenized so the number is stored securely.
How can I maximize my billing with a full schedule of patients—while also adhering to AMA and Medicare rules?
Staying on top of billing rules and regulations per payer—while also providing exceptional patient care and running a practice—can be a lot for any provider, which is why we recommend using a quality software or service to help. After all, your ability to garner proper reimbursement for your services is essential to you not only staying in business, but also making enough money to grow and better serve your patients.
We're having problems billing secondary insurances when the primary payer has a day rate (e.g., UHC/Optum has a rate of $75 per visit). The primary considers up to $75 of the billed charges and adjusts the remainder per the contract rate agreement. But, the secondary processes the claim with their allowables for each line item and pays the first item that the primary allowed, but denies payment for all subsequent items. How should we manage this scenario?
Let's say you bill Optum, and that payer allows $75. Now, let’s also assume the patient has a $20 copay, which you collected at the time of service. Optum then pays your practice $55. When you send the EOB or RA to the secondary payer, in our experience, all they will pay is the $20 copay. They will not pay above the $75 dollars allowed by Optum.
Should we be regularly auditing our documentation? If so, how frequently?
Yes. You should implement a regular process of auditing your documentation for defensibility on a consistent schedule. The scale of your audit will depend on the size of your practice and available resources. The more thorough, the better. After all, better you than Medicare. Download your free copy of our defensible documentation toolkit—in it, you’ll find a checklist to review your documentation against.
How much should we be paying for an RCM service? How do we know we’re getting our money’s worth?
Just because you outsource doesn’t relieve you of providing the same level of accountability that you would demonstrate when billing in-house: you should know the KPIs you are tracking, nail down the benchmarks for those KPIs, and compare them monthly. The rate question is harder to answer, because it depends on what you get for what you pay:
- Is there software?
- Are there software fees?
- Are there statement fees or postage fees?
- Do you have to post your in-office payments, or does the service to that?
- What kind of reporting and transparency is available?
- How does the billing service provide that?
- Does your RCM team meet with you (in-person or remotely), and if so, how often?
These are all important questions to consider. You’ll see rates as low as 2.5% all the way up to 10%. So, be clear on what, exactly, you’re paying for.
How do you handle billing when a patient comes in with a new diagnosis for another body part?
If the new diagnosis is unrelated to the original plan of care, you would perform another evaluation rather than a re-evaluation. After you’ve evaluated the new issue, you can combine the care plans into one case if you so wish.
How do you handle billing when a PT and OT are sharing a case?
According to Meredith Castin, billing for PT and OT treatment on the same day can be challenging, but doable. Check out this blog post to learn more.
Do you know of any good, inexpensive billing or coding training courses? I’m not looking to get a degree or certificate—just more knowledge.
Not to toot our own horn, but we have a plethora of free, high-quality billing and coding knowledge that’s available to the public!
- Physical Therapists’ Guide to Billing
- WebPT billing blog articles
- WebPT billing webinars
- WebPT billing downloads
What tactics should I use to collect patient balances?
As much as possible, implement practices and policies that prioritize point-of-service collection. In other words, don’t allow patient balances to accrue to the point where you need to chase down payment. To facilitate easy patient payment, be sure that you stay up on insurance eligibility, establish a check-out process that includes payment collection, and allow several payment methods (cash, credit card, etc).
What is the average time for claim submission and, after its been processed, how much time do we have to work on denials before the insurance company won’t pay?
With Medicare, you have up to one year from the date of service to submit the claim. If it is denied, you have 60 days from the date of the remittance advice to file an appeal. Outside of Medicare, timely submission guidelines are payer dependent, so be sure to check with each payer.
Is there an efficient way to verify insurance coverage for patients with out-of-state insurance rather than calling on each one?
Some payers have online portals that you can use to verify; otherwise, it’s necessary to reach out by phone.
Do you recommend charging no-show fees? If so, how much?
We do recommend charging no-show fees—and outlining your cancellation policy in your intake form, so everyone is on the same page. It’s hard to provide a recommendation on how much to charge, because that will depend heavily on what’s appropriate in your market. Some cash-pay providers charge half of the session rate; some in-network providers charge a flat $20 cancellation fee. As a note, Medicare does allow providers to charge no-show fees as long as the following conditions are met:
- “Has a written policy on missed appointments that is provided to all patients. (Providers may also want to obtain patients' signatures to acknowledge receipt of this policy as an extra preventive measure).
- “Ensures that the missed appointment policy applies equally to all patients.
- “Establishes that the billing staff is aware that Medicare beneficiaries should be billed directly for missed appointments.
- “Ensures that charges for missed appointments are reflective of a missed business opportunity and not the cost of the service itself.”
That said, most Medicaid policies prohibit providers from charging these types of fees. Because Medicaid is state-run, it’s best to review your specific Medicaid policy to see how your state handles fees for Medicaid patients.
Wow, that’s a lot of physical therapy billing info! Still have a question? Leave it in the comment section below, and we’ll do our best to get you an answer.