Coding and Billing Physical Therapy:
Billing and Coding for Physical Therapy services may be tricky and might affect
your reimbursement. These services are only covered if medically necessary.
Coverage based on the diagnosis and the patient’s condition should also be
determined. The patient’s diagnosis may be different of that from the
referring physician. The plan of care and the duration of the care must also
be carefully determined.
Physical Therapy under Medicare are not covered not unless the referring
physician that the services is medically necessary for the beneficiary’s
condition. The referring physician must establish a written treatment plan for
physical therapy services. This must be reviewed every 30 days and must be
re-certified should the patient need to continue Physical Therapy.
CPT Code 97001 Physical Therapy Evaluation
CPT Code 97002 Physical Therapy Re-Evaluation
CPT Code 97110 Therapeutic procedure, one or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of
motion and flexibility
CPT Code 97112 Neuromascular reeducation of movement, balance,
coordination, kinesthetic sense, posture, and/or proprioception for sitting
and or standing activities
CPT Code 97116 Gait Training (includes stair climbing)
CPT Code 97124 Massage, including effleurage, petrissage and/or
tapotement (stroking, compression and percussion). (For Myfascial release,
CPT Code 97140 Manual Therapy Techniques (eg.
mobilization/manipulation, manual lymphatic drainage, manual traction), one
or more regions, each 15 minutes
CPT Code 97150 Therapeutic procedure(s), group (2 or more
individuals). Report 97150 for each member of the group.
(Do you know your Modality Codes - Supervised and Constant Attendance
Codes? -- READ MY OTHER POST ON THESE CODES AND HOW TO BILL
Common Mistakes in Reporting and Billing Physical Therapy Services:
1. Billing for example, the therapeutic exercise CPT Code 97110 for 3
units, 97110 code is being entered thrice on each line on the claim form
2. Improper reporting of number of units for timed codes/services
3. No referring physician information on the claim
4. Poor Medical Documentation
Billing Timed Services such as 97110, 97140 and 97112:
Do not report any service done less than 8 minutes!
8 minutes to 22 minutes is billed as 1 unit
23 minutes to 37 minutes is billed for 2 units
38 minutes to 52 minutes is billed for 3 units
All timed services must be documented on the medical record of the patient.
Know More how the CMS "8" - Minute Rule Works.
Modifier Used for Physical Therapy Services:
GP Physical Therapy service rendered by a Physical Therapist
59 Distinct Procedural Service
*** use modifier -59 for second and subsequent modality, multiple/different
97112 for Neck>> 97112 GP >> 723.1
97112 for Back >> 97112 GP 59 >>724.2
READ MORE ON MY POST ON: Coding and Billing Physical Therapy Services
CMS - "8" Minute Rule for Billing Units
Medicare Coverage and Payment Conditions:
(Rev. 36, Issued: 06-24-05, Effective: 06-06-05, Implementation: 06-06-05)
• Therapy services are or were required because the individual needed
therapy services* (see §220.1.3 - Certification and Recertification of Need for
Treatment and Therapy Plans of Care); and
• Plan of care for furnishing such services has been established by a
physician/NPP or by the therapist providing such services and is periodically
reviewed by a physician/NPP* (see §220.1.2 - Plans of Care for Outpatient
Physical Therapy, Occupational Therapy, or Speech-Language Pathology
• Therapy services are or were furnished while the individual is or was under
the care of a physician* (see §220.1.1 - Outpatient Therapy Must be Under
the Care of a Physician/Nonphysician Practitioners (NPP) (Orders/Referrals and
Need for Care)); and
• Services must be furnished on an outpatient basis. (See §220.1.4 -
Requirement That Services Be Furnished on an Outpatient Basis)
* Physician Orders, Referrals, and Necessity for Care)
An order or physician referral/script is not enough to prove medical necessity
and involvement of the physician. A certification for plan of care must be
certified by the referring physician. Rember, "reimbursement relies on the
certification of the plan of care and not just that of the order". Though the
order is important to determine if the patient is under the care of the
physician, and the physician must be there to provide certification for the plan
* The plan of care must be established first before treatment begins. The
plan of care, must be signed by the professional healthcare provider who
established the plan, date it and must be documented with the plan.
From the Medicare Benefits Policy Manual; it says:
“Treatment under a Plan. The evaluation and treatment may occur and
are both billable either on the same day or at subsequent visits. It is
appropriate that treatment begins when a plan is established.”
"Therapy may be initiated by qualified professionals or qualified personnel
based on a dictated plan. Treatment may begin before the plan is
committed to writing only if the treatment is performed or supervised by
the same clinician who establishes the plan. Payment for services provided
before a plan is established may be denied.”
“Two Plans. It is acceptable to treat under two separate plans of care when
different physician’s/NPP’s refer a patient for different conditions. It is also
acceptable to combine the plans of care into one plan covering both
conditions if one or the other referring physician/NPP is willing to certify the
plan for both conditions. The Treatment Notes continue to require timed
code treatment minutes and total treatment time and need not be
separated by plan. Progress Reports should be combined if it is possible to
make clear that the goals for each plan are addressed. Separate Progress
Reports referencing each plan of care may also be written, at the discretion
of the treating clinician, or at the request of the certifying physician/NPP,
but shall not be required by contractors". ~~~~ Citations/References:
220.1.2 - Plans of Care for Outpatient Physical Therapy, Occupational
Therapy, or Speech-Language Pathology Services (Rev. 88, Issued: 05-07-
08, Effective: 01-01-08, Implementation: 06-09-08) Reference: 42CFR
410.61 A. Establishing the plan (See §220.1.3 for certifying the plan.)
https://www.cms.gov/manuals/Downloads/bp102c15.pdf (Rev. 145, 07-08-
Plan of Care must include:
- Long term treatment goals
- Type, amount, duration and frequencey of therapy services
With the type of treatment, the therapy specialty must be determined either
OT, PT or SLP. If two different therapy discipline is treating the same patient,
there must be different plans of care for each type of discipline. In other
words, a Physical Therapist can not treat a patient under the Occupational
Therapist's treatment plan. Both can also treat the patient on the same day
at different times dependent on their scope of practice. Both OT, PT services
are also billable.
Initial Certification must be obtained as soon as possible after the treatment
plan is established. Or within 30 days.
Recertification must be obtained before or during the treatment.
Recertification may have up to 90 days duration for care, based on the
Documentation in the patient’s medical record should include proper
evaluation leading to the diagnosis of the trigger points, specific identification
of the affected muscle(s). It must also be properly documented the reason
why injections are the chosen as a treatment option.
**** For more references: Consult your CPT code books. The National
Correct Coding Initiative (NCCI) and third pary payer payment policies and
READ MORE: 11 Part B Billing Scenarios for PTs and OTs (from CMS Website)
Medicare Claims Processing Manual
Chapter 5 - Part B Outpatient Rehabilitation and CORF/OPT Services - you will find here
CMS 8-Minute Rule for Billing and a Lot More!
Read the OIG (Office of the Inspector General) Report ~ "QUESTIONABLE BILLING FOR
MEDICARE OUTPATIENT THERAPY SERVICES" (December 2010 OEI-04-09-00540)
COMPLIANCE IS A MUST IN ANY MEDICAL PRACTICE. ETHICS PLAYS A VITAL ROLE.
EDUCATION & PROPER KNOWLEDGE OF YOUR OFFICE STAFF IS VERY IMPORTANT.
THERE IS NO EXCUSE FOR IGNORANCE.