Of course, you got into physical therapy to help people—not to rake in the dough. But in order to do the former well, you’ve also got to know how to make a profit—and that requires billing for your services. If you’re new to physical therapy, you might be feeling a little overwhelmed by the prospect, so here are a few things to remember about billing for physical therapy services—the basics, if you will.

(Keep in mind that this is by no means a comprehensive post, so we definitely recommend you seek the services of a billing expert before beginning to bill.)

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The Codes

ICD

In order to bill for your services, you’ll need to include a diagnosis that demonstrates the medical necessity of your care using the latest version of the International Classification of Diseases code set, which for right now is ICD-10.

According to the American Physical Therapy Association (APTA), the first-listed diagnosis you use for billing should be reflective of “the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.” That’s part of the reason why it can be challenging to decide which ICD code to use. The APTA suggests choosing the most specific “code that most accurately describes the condition you are treating based on the objective evidence.”

To ensure you choose a code that’s reimbursable under the payer’s payment policy, you can always call the payer before you submit a claim. According to the APTA, “Your goal is to maximize the number of claims that are paid on the first submission and to minimize the need for appeals.” So when in doubt, ask.

CPT

The American Medical Association developed the Current Procedural Terminology (CPT®), which is “the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs.” According to the American Physical Therapy Association, “when billing most third parties for services...it is necessary to utilize CPT-4 codes to describe the services that were rendered. Although CPT is not an exact description of physical therapists’ interventions, it does provide a reasonable framework for billing.”

Most of the CPT codes that are relevant to rehabilitative therapists are located in the 97000s (“Physical Medicine and Rehabilitation”). However, clinicians can bill any code as long as they can legally provide that service under state law. The APTA notes, though, that just because a provider can legally bill for a code doesn’t mean a payer will reimburse for it.

The American Academy of Orthopaedic Surgeons (AAOS) recommends that you familiarize yourself with the following CPT categories before billing for physical or occupational therapy services:

  • Evaluations (97161-97163 for PTs and 97165-97167 for OTs) and reevaluations (97164 for PTs and 97168 for OTs)
  • Supervised (un-timed) modalities (97010–97028)
  • Constant attendance (one-on-one) modalities (97032–97039) (billable in 15-minute increments)
  • Therapeutic (one-on-one) procedures (97110–97546)
  • Active wound care management (97597–97606)
  • Tests and measurements (97750–97755)
  • Orthotic and prosthetic management (97760–97762)

Learn everything you need to know about PT billing—all in one handy resource. Download your free copy of the PT’s Guide to Billing today.

The Terminology

The AAOS also provides a compilation of important terminology. Chances are you already know these, but just in case, here’s a refresher (definitions adapted from this AAOS article, this APTA one, and this WebPT one):

  • Treatment: This encompasses all therapeutic services.
  • Service-based (supervised or untimed) CPT codes: These are the codes you’d use for things like conducting a physical therapy evaluation or applying hot/cold packs. For these types of services, it doesn’t matter if you complete the treatment in ten minutes or 35, because you can only bill for one code.
  • Time-based (constant attendance) CPT codes: These codes allow for variable billing in 15-minute increments when a practitioner provides a patient with one-on-one services, such as therapeutic exercise or manual therapy.
  • Order (referral): In many cases, a physician will provide an order or referral for therapy that includes a diagnosis and instructions for treatment type, duration, and frequency.
  • Evaluation/Reevaluation: The evaluation typically occurs on the patient’s first visit and includes an examination, which consists of a review of historical data and systems as well as tests and measures. It is at this point that the therapist provides a diagnosis and prognosis. A therapist should perform a reevaluation if the patient’s condition or functional status changes unexpectedly.
  • Plan of care: Based on the evaluation, the therapist works with the patient to develop a plan of care to help the patient meet his or her therapeutic goals. If the physician provided a referral for therapy, the therapist will build the plan of care around the details of the physician’s order.
  • Initial certification: Medicare requires ordering physicians to “approve or certify the plan of care via signature in a timely manner (within 30 days of the evaluation).” The initial certification covers the first 90 days of treatment. To continue treatment past the first 90 days, you must receive recertification from the ordering physician.
  • For Medicare patients, therapists must complete a progress report at minimum every tenth visit.
  • Discharge note: Once treatment is complete, therapists must complete a discharge note that, according to the AAOS, “details the patient’s treatment and status since the last progress note.” (Note that “writing the progress note and discharge note are not separately billable services for the therapist, but are required for Medicare documentation.”)

As you can see there’s a lot to cover. And there’s more where this came from, so check back tomorrow for Part 2 of our Physical Therapy Billing for Beginners post.

Also, be sure to check out this handy PT billing FAQ.

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