Most physical therapists have a passion to treat patients, but they also need the requisite skill set to successfully navigate the world of physical therapy CPT Codes. Whether you operate your own private practice, or you are working in a multi-therapist clinic, you will need to understand these codes, as accurate billing and receiving payment from your patients does require a familiarity with them and what they mean for reimbursement purposes.
Key Steps For Physical Therapists To Follow for Correct CPT Billing
- The use of CPT Codes is to identify the services rendered. However, it is not the diagnosis. The codes used should reflect the procedure performed.
- When selecting timed codes, such as 97110 (therapeutic exercise) and 97140 (manual therapy), it is important to choose based on the type of session, length of session, and the types of interventions performed.
- Modifiers such as 59, GP and KX should be applied when billing for multiple services or billing for services that exceed Medicare thresholds to help prevent issues with claims.
- Payer policies must be understood and followed precisely along with correct coding guidelines (i.e., 8-Minute Rule). For example, therapists must use the correct complexity code (i.e., 97161-97163) based on their assessment of a patient’s physical and/or functional status, in order to avoid billing errors and ensure PT reimbursement at the highest level.
- A trusted medical billing company , like Park Medical Billing, provides therapists with the necessary tools they need for billing and practice management, including EHR integration, accurate billing, revenue cycle management and practice management solutions.
CPT stands for Current Procedural Terminology Codes, the physical therapy CPT codes used by physical therapists are how therapists describe the services performed when submitting a claim to a third-party payer. Physical therapy billing service providers must select the appropriate CPT Codes based on the types of interventions provided and the duration of each intervention. CPT Codes are a uniform language that all healthcare providers use when coding services and procedures they provide to patients, allowing for the clear communication of care given and the accurate documentation of billing activities.
What CPT Codes Are Most Frequently Utilized by Physical Therapists?
The following are some of the regular CPT codes for physical therapy used by physical therapists that every professional should know.
| CPT Codes | Title | Description |
| 97110 | Therapeutic exercise | Exercises given in sessions lasting 15 minutes to help improve strength, movement, and flexibility. Activities require therapists to be present and involved during each treatment. |
| 97112 | Neuromuscular re-education | Therapy for balance, body coordination, posture, and body awareness. Methods may include guided movements, balance drills, and retraining your body for daily activities. |
| 97116 | Gait training | Focuses on teaching better walking skills and safe stair use. Aims to boost walking technique and help cardiovascular health when appropriate. |
| 97140 | Manual therapy | Involves skilled hand movements to improve joint or soft tissue movement, relax muscles, or ease pain. Techniques can include stretching, massage, and manipulation performed by hand. |
| 97530 | Therapeutic activity | Uses dynamic tasks to help restore everyday functions. Patient performs multiple movements such as lifting, balance exercises, and shifting positions with guidance. |
| 97535 | Self care/Home management training | Therapy teaching skills for daily living, such as self-care, adapting home items, or instructions for home-based equipment use, like TENS units or dressing supports. |
| 97530 | Physical performance test/measurement | Consists of targeted movement tests and strength checks for better function. Times and measures each part but does not duplicate what’s covered in exercise assessments. |
| 97161 | Low Complexity Evaluation | Assessment done when there are no serious additional health factors. The plan covers one or fewer personal issues, and the overall condition is safe and stable. |
| 97162 | Moderate Complexity Evaluation | Assessment for cases with some health complications. The plan may address two or more issues involving body structure or participation. Presentation may limit daily activities somewhat. |
| 97163 | High Complexity Evaluation | Used for cases with serious complications affecting care. Evaluation will address multiple physical or social factors and involve a broad plan for improvement. |
| 97164 | Physical therapy re-evaluation | Check-up after therapy plan changes, including new therapy tests and updated treatment approach to ensure improvement continues. |
The following are some of the regular CPT codes for physical therapy used by physical therapists that every professional should know.
How Do Timed Units Work for Physical Therapy Services?
When submitting claims to payers, physical therapy providers bill for services according to timed units. Most CPT codes are structured using 15-minute increments, so it is important for all therapists to familiarize themselves with each payer’s policy. The 8-minute rule is an important part of billing by time, especially in with regards to Medicare. In order to bill for one CPT unit, therapists must deliver a minimum of 8 minutes or more of a specific treatment (CPT). Therefore, if you provide treatment for 23 minutes, you may submit a claim for two units. If you provide 38 minutes, you may submit a claim for three units; and if you provide 53 minutes, you may submit a claim for four units.
According to the 2021 CPT Manual on page XVII, the following guidelines assist with determining how to appropriately bill for 1 unit. When you reach the midpoint of a caption of 15 minutes (7 minutes 30 seconds), you can bill for one timed unit. However, the CPT does not specify that you need to add any additional minutes to qualify for billing more than one timed unit. So, if you understand this information, you will know how to properly bill for your time in physical therapy.
The five digits of every physical therapy code consists of numbers, letters and special characters. The 97000 series is classified as Physical Medicine and Rehabilitation, but it is also important for the provider to look for other codes outside this series. A provider should only bill with codes that correctly describe the services they render and are allowed by the state licensing laws.
As there are on-going changes to both the editorial and application aspects of these codes, it is strongly recommended that providers consult with timely sources such as the American Medical Association, the organization that owns the copyright for these codes. It is important to note that due to the vast number of payers, and that none of them all pay for all of the 97000 series codes, it is critical that providers check each payers’ published payment policies prior to using those codes for billing receipts.
Understanding the Physical Therapy CPT Code Billing
The completion of the treatment note including the proper codes starts the billing process for a physical therapy session, as documented and signed by the licensed professional or business. The therapist or business must accurately code with respect to the service provided, using appropriate CPT codes for physical therapy to make sure that the bill will be correctly submitted, whether it is sent directly to the patient, a third-party payer, or an intermediary claims clearinghouse.
The use of required modifier codes, including Modifier 59, must be included on every billing cycle to make sure of accuracy. Modifier 59 is specifically addressed on both the CMS website and within the CPT manual. This modifier is used to identify procedures or services that are substantially distinct and separate from all other non-E/M services performed on the same day.
When two services identified by timed codes are performed during a single encounter but were performed in sequence, Modifier 59 is necessary to document the sequence of service. For codes that are billed based on time, such as 15-minute increments or hourly blocks, Modifier 59 is also appropriate. When two timed services are rendered in separate sections of time and do not overlap in relation to each other, Modifier 59 is necessary for documentation of the services rendered separately.
CPT code 97140 includes the use of manual therapy techniques (mobilization, manipulation, manual lymphatic drainage, or manual traction) performed over one or multiple regions for a maximum of 15 minutes total on the same day. Each separate procedure counted towards the 15 minutes towards the overall value of therapy.
- If two different procedures are being performed in the same distinct 15-minute period, modifier 59 can be billed.
- The first 15 minutes of a procedure may be totally separate from a second procedure performed in the second 15 minutes.
- Therapy time blocks may also be combined (i.e., 10 minutes of manual therapy, 15 minutes of therapeutic activities, and another 5 minutes of manual therapy, all together).
- CPT code 97530 cannot be used and modifier 59 cannot be added for procedures completed within the same time period.
Modifiers such as XE, XS, XP, and XU (created January 1, 2015), have provided additional, more specific billing options for situations that may have had modifier 59 before. In other words, the new modifiers provide more precise identification of the encounter (XE), the structure (XS), the practitioner (XP), and the unusual or distinct service (XU), in place of using modifier 59, where applicable.
If you are submitting an outpatient physical therapy claim, always include an ‘GP’ modifier so that the payer knows that the service was initiated under a physical therapy plan of care.
Medicare’s physical therapy cap is a threshold that was established after 2018. This means that if a physical therapist provides outpatient services and has incurred expenses exceeding $2,110 for that patient, the billing must contain the KX modifier to indicate that the patient’s continued service is medically necessary. The documentation must demonstrate that these continued services are medically necessary. As of January 1, 2021, the KX modifier should be on any billing for incurred expenses exceeding $2,110 for both physical therapy and speech-language pathology.
Due to changes in the way many providers are now billing for physical therapy services, many have changed from using a paper to an electronic claim form system. The most frequently used claim form is the Universal Claim form CMS-1500, although some payers provide their own billing forms. Whether you use a paper or electronic method of submitting a physical therapy claim, you should be aware of the submission process and make sure that all information is accurate.
There are two ways to submit a claim. Either directly to the payer or via a claims clearinghouse. Claims submitted electronically fall under the jurisdiction of the HIPAA (Health Insurance Portability and Accountability Act), enacted in 1996, which specifies that these claims must meet rigorous standards, as all claims submitted in paper form must be complete, accurate, and legible.
A clean claim contains all the required elements and is free of any defects. Having clean claims allows for an uninterrupted billing cycle and expedites payment. It is necessary for both paper claims and electronic claims to be reviewed prior to submission to make sure of their cleanliness.
It is important for physical therapy practices to be educated on proper methods for processing CPT codes, assigning CPT codes and submitting claims. Improper use of CPT codes or inaccuracies in submitting claims can jeopardize an entire practice. Implementing proper procedures will promote comfort and confidence for those involved in billing on a daily basis.
How Park Medical Billing Empowers Physical Therapy Practices
Rather than being an EHR solution, Park Medical Billing is an expert billing provider that integrates with existing EMR/EHR systems. For active physical therapy clinics, Park will handle all of your billing needs and manage your entire revenue cycle so you may devote your full attention to patient care instead of spending your time on billing or administrative tasks.
What Makes Our Integration Different?
- Seamless EMR/EHR Sync: Park Medical Billing provides a secure synchronisation solution for most leading EMRs, such as Therabill, Fusion and WebPT, by directly accessing their respective billing data. As a result, there is no need for the business to duplicate entries or switch applications each time a billing transaction occurs.
- Human Expertise + Smart Automation: Park Medical Billing uses both human judgement and intelligent automation when performing billing tasks. While other companies may provide solely a software-based solution, we use the experience of trained billers together with intelligent automation to maximize the efficiency and productivity of our billing team. In this way, all billing claims are processed and reviewed by trained professionals who are experienced in billing for physical therapy and supported by tools that help identify and correct routine billing errors and expedite billing procedures.
Here’s how Park Medical Billing supports your practice:
- Claims Management: We prepare, batch, scrub, and submit claims for clients with verified accuracy and compliance before they leave our office. Most rejected claims are resolved the same day.
- Invoicing to Patients: We generate and send statements and bills directly out of your EMR/EHR records automatically, with follow-up reminders.
- Verification & Authorization of Insurance: We review the verification of benefits and assist with pre-authorization on behalf of clients to avoid any unpaid visits or denials.
- Follow-up and Appeals: Our billing experts will pursue the reconciliation of underpaid/rejected/late claims to recover additional revenue for our clients that may not have been pursued by other service providers.
- Posting and Tracking of Payments: We match every payment received from an insurer or patient to the corresponding claim, then post and reconcile the payment to your own systems for real-time visibility into your revenue.
- Transparent Reports: You will receive before and after tax customized financial reports to evaluate aging summary reports, denial trend reports, and revenue split reports by profit center.
Why Physical Therapists Choose Park Medical Billing
- No Learning Curve With Our Software: We will work with the systems you already have in place. There is no additional set-up and no new system to learn.
- Real-Time Support: We provide an assigned billing manager to answer your questions or explain your revenue trends as you need them, so you don’t have to wait on hold for an hour.
- Lower Denial Rates & Faster Payments: By combining the best of both EMR/EHR technology and billing experience we develop unique solutions that will see your practice experience fewer denials and receive their payments faster than they would without our services.
Park Medical Billing offers your clinic’s real needs in addition to a basic clearinghouse or automated tool. We partner with you on a continuous basis. If you are interested in having us do your billing and integrate into your EMR/EHR system, please reach out so we may show you how to improve your bottom line.
