Is your relationship with billing complicated at best? I get it. Billing for private practice physical therapy can seem daunting, especially in light of ever-changing regulations. But unless you own a strictly cash-pay clinic, you can’t practice—or get paid—without it. I’m not asking you to love billing, but to help your clinic succeed, you need to understand it. Here’s how to get started:
If you haven’t already gotten credentialed, you’ll need to start here. Being credentialed with an insurance company allows you to become an in-network provider. Why is that important? Depending on your patient’s specific insurance policy, if you don’t go through the credentialing process, you may not receive payment for your out-of-network claims. Most government insurance companies don’t pay out-of-network providers. Furthermore, if you’re not credentialed with Medicare, you cannot treat—or collect payment from—Medicare patients for any Medicare-covered services.
Additionally, being a credentialed provider gives you more exposure. Patients often check their insurance company’s website for a list of local providers; if you aren’t a credentialed provider with that company, you won’t be in their list.
However, getting credentialed isn’t exactly a short, simple process, and there are some hoops you must jump through, including obtaining:
- malpractice insurance,
- an NPI,
- an actual clinic location, and
- a license to provide services in your state.
Plus, if any of your therapists worked previously at another clinic, you’ll need to determine if they were credentialed as a group or an individual provider. If they don’t have their own contract, they likely aren’t covered.
If you need help navigating the credentialing process, consider reaching out to a local, established private practice therapist for advice or seeking the assistance of a paid consultant who can take care of the paperwork for you.
Cozy up to codes
Billing is a numbers game—and thanks to ICD-10, it’s a letters game, too. Confused? Read on.
Developed and maintained by the American Medical Association, the Current Procedural Terminology (CPT®) is a registered trademark of the AMA and 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 (APTA), most third-party payers require PTs to bill using CPT-4 codes (coding for interventions) for services rendered—not diagnoses.
It’s important for your billing team to understand how CPT codes work. In this article, the American Academy of Orthopaedic Surgeons (AAOS) identifies the key service categories you need to know, including:
- Evaluations and reevaluations
- Supervised (untimed) modalities
- Constant attendance (one-on-one) modalities (billable in 15-minute increments)
- Therapeutic (one-on-one) procedures
- Active wound care management
- Tests and measurements
- Orthotic and prosthetic management
Many of the above rehab therapy-relevant CPT codes are located in the 97000s (if they were zip codes, we’d be hanging out in Oregon—go Beavs!), but they aren’t the only codes you’ll use because “a provider can bill any code as long as the provider can legally render that service according to state licensure laws.” But biller beware: the APTA warns that providers don’t have to reimburse for codes “just because a code exists and is utilized by a provider,” so you’ll want to check each payer’s payment policy.
The latest and greatest in the International Classification of Diseases will officially come in to play on October 1, 2015. Once the transition occurs, all HIPAA-covered entities must report ICD-10 codes instead of ICD-9 codes in order to receive reimbursement for their services. Unlike CPT codes, ICD codes indicate diagnosis—in particular, a diagnosis that demonstrates the medical necessity of your care—so it’s a good thing ICD-10 allows for a much greater level of specificity in coding patient diagnoses.
But getting a grip on ICD-10 will take some time and effort because the new code set contains about five times as many codes as its predecessor—approximately 68,000 to ICD-9's 13,000. Plus, ICD-10 features an entirely new code structure with three to seven characters in an alpha-numeric combination; ICD-9 codes consisted of only three to five characters with a decimal point (e.g., 813.15). To keep your cash flow moving at top speed, aim to maximize first-time submission acceptance rate. To do so, you’ll need to train yourself on ICD-10 codes to help you get it right the first time, every time.
Nail down billing starting with the front office
What happens in the front office is just as important as what happens in the back office. Why? Because appropriate and successful billing starts the moment a patient walks into your practice—and doesn’t end until the patient is finished with treatment. Your staff needs to work together to ensure a seamless billing process. When it comes to billing, the devil’s in the details—and there are a lot of them. Taking the time to focus on the small stuff can mean the difference between a clean claim and a denial. Here are a few things to keep in mind:
- Teach your staff rehab therapy terms. It’s tough to bill correctly if you don’t understand the difference between an evaluation and an initial certification or a progress report and a reevaluation. Planning to work with a lot of direct access patients? You’ll need to train your staff on that, too.
- Partner with the right software. A few folks still accept paper claims (like CMS 1500), but most payers—including Medicare—only accept electronic claims, so it’s a good idea to work with a billing vendor to prepare and submit your claims. Even better? Work with an EMR that integrates with your billing software to eliminate double data-entry and reduce claim errors. Just make sure the vendor fully complies with HIPAA regulations.
- Verify insurance with the patient and the insurance company. Obtain the insurance company name, ID number, and group number from the patient, then contact the insurance company to make sure the patient’s plan is active and covers rehab therapy.
- Determine if the insurance company requires a referral before you can begin treatment.
- At each visit, confirm—and obtain—the patient’s copay (or coinsurance) and double-check deductibles. Make sure the patient isn’t behind on payments and that previous claims haven’t been denied. You also need to confirm and/or update the patient’s insurance. A new calendar year or a new job can dramatically change insurance plans, copays, and deductibles.
It would be impossible to completely cover all the ins and outs of billing, but this post should help you get more comfortable with this complicated—yet critical—piece of your business. Once you’ve conquered the basics, we’ve got some tips to maximize your billing and optimize your claims. Totally overwhelmed and considering letting someone else handle billing for you altogether? Check out this post to determine the right billing method for your practice.