Procedure codes for Physical Therapy

While your ultimate mission as a physical therapist is to improve your patients’ quality of life, the financial sustainability of your clinic is equally significant. One of the primary challenges faced by physical therapy clinics is not a shortage of patients or billable sessions, but rather the prevalence of billing errors.

An area that proves to be particularly troublesome in physical therapy billing is accurately determining the fees charged to patients. When insurance companies perceive that sessions have been billed erroneously or unnecessarily, it leads to delays in claims processing.

To address this issue, the American Medical Association (AMA) introduced the Current Procedural Terminology (CPT) codes. These CPT codes play a pivotal role in ensuring the accurate processing of health insurance claims for physical therapy clinics. However, it’s crucial to grasp the correct utilization of each code. Misapplying these codes can result in complications during insurance claims processing, potentially affecting the financial stability of your clinic. In this guide, we will explore the most common physical therapy CPT codes and provide insights into their appropriate usage.

Billing challenges faced by a physical therapy provider:

When patients with medical coverage meet the necessary criteria for physical therapy, they naturally expect their insurance to cover the costs. However, the insurance companies wield considerable authority in determining the necessity of such care, subjecting it to rigorous evaluation.

One significant factor that can influence insurance coverage is the patient’s functional status. If an insurance provider deems the patient “functional,” they may decide not to cover the expenses associated with physical therapy, creating financial implications for the patient.

Conversely, even when a patient qualifies for coverage, insurance companies can introduce delays or, at times, fail to process claims due to seemingly minor technicalities. Successfully navigating these intricacies requires healthcare providers to have a comprehensive understanding of how to accurately bill patients and submit claims. This entails proficiency in employing physical therapy CPT codes and ensuring the submission of error-free insurance claims.

Group therapy services are a common type of treatment in physical therapy. Group therapy allows physical therapists to treat multiple patients with similar conditions simultaneously. This can be an effective way to improve patient outcomes and reduce costs. However, billing for group therapy can be complex. Physical therapists must ensure that all participants in the group therapy session are eligible for the services provided and that the correct number of units are billed for each patient.

To bill for group therapy, physical therapists must first identify the specific service codes that apply to the services provided. There are several different service codes for group therapy, depending on the type of service provided and the number of participants in the group.

Common Physical Therapy CPT Codes:

1. 97110 – Therapeutic Exercises: This code covers exercises and activities that help improve a patient’s strength, endurance, flexibility, and range of motion.
2. 97112 – Neuromuscular Reeducation: It includes exercises designed to enhance balance, coordination, and posture.
3. 97116 – Gait Training: Used for therapy aimed at improving a patient’s ability to walk.
4. 97140 – Manual Therapy: This code is for hands-on techniques used by physical therapists to alleviate pain and enhance joint mobility.
5. 97150 – Group Therapeutic Procedures: Applicable when physical therapy is provided in a group setting.
6. 97530 – Therapeutic Activities: This code encompasses dynamic activities that improve functional performance.
7. 97535 – Self-Care/Home Management Training: It includes education and training to help patients regain independence in daily activities.
8. 97164 – Physical Therapy Evaluation: Used for the initial evaluation of a patient’s condition.
9. 97168 – Reevaluation: Applicable for the assessment of a patient’s progress during ongoing treatment.
10. 97542 – Wheelchair Management Training: This code is for training patients to use a wheelchair effectively.
11. 97750 – Physical Performance Test or Measurement: This code is used to report assessments that measure a patient’s physical abilities and functional status.
12. 97761 – Prosthetic Training: This code is utilized when a patient is receiving training to use a prosthetic device, such as an artificial limb. It may involve fitting, adjustment, and patient education on using the prosthesis.
13. 292, 295 – Strapping: These codes are used for the application of strapping or taping techniques to provide support, stability, or restriction of motion. The specific code chosen depends on the location and type of strapping.
14. 90901, 90911 – Biofeedback: These codes are used for biofeedback training sessions. Biofeedback is a technique that helps patients gain voluntary control over physiological functions.
15. 97755 – Assistive Technology Assessment: This code is employed when an evaluation is conducted to determine the need for assistive technology devices or services. It may involve assessing the patient’s functional capabilities and matching them with appropriate technologies.
16. 97760 – Orthotic Management and Training, First Encounter: This code is used when a patient receives the initial training and fitting for an orthotic device. Orthotic devices include braces and supports for various body parts.
17. 97761 – Prosthetic Training, First Encounter: Similar to orthotic management, this code is used for the initial training and fitting of a prosthetic device.
18. 97763 – Orthotic/Prosthetic Management, Subsequent Encounters: After the initial fitting and training, this code is used for follow-up encounters related to orthotic or prosthetic management.

Physical Therapy Modifiers 

Physical therapy modifiers are used to report specific information about the services provided, such as whether they were performed during separate time blocks, by different practitioners, or to treat different structures. They help to ensure that providers are reimbursed accurately for the services they provide.

• Modifier 59: Used to report two distinct procedures performed during the same session, if they are performed in different 15-minute time blocks or split across two different therapy sessions.
• Modifiers XE, XS, XP, XU: Used to provide greater reporting specificity in situations where Modifier 59 was previously reported. These modifiers can be used to indicate a separate encounter (XE), separate structure (XS), separate practitioner (XP), or unusual, non-overlapping service (XU).
• Modifier GP: Must be used when submitting an outpatient physical therapy claim to indicate that the services were provided under a physical therapy plan of care.
• KX Modifier: Must be used to report medically necessary physical therapy services provided to a patient after the Medicare physical therapy cap has been reached.

Common Billing Errors:

1. Fixed Rate Payers: These payers follow a capped daily maximum payment model. It’s crucial to understand that this doesn’t imply a flat payment regardless of the services provided. You must bill for the actual services rendered, ensuring you reach the daily maximum through accurate billing.
2. Excessive Use of Specific Codes: Insurance companies closely monitor code usage. Providers who excessively use a particular code, compared to industry norms, may trigger audits or reviews. It’s essential to maintain a balanced and accurate code utilization.
3. Timing Accuracy: Proper timing calculation for services includes pre-treatment, intra-treatment, and post-treatment phases. Precision in time documentation is vital for correct billing and reimbursement.
4. Accurate Code Selection: While it might seem straightforward, choosing the right code is critical. For instance, an exercise can potentially fit under various codes, such as therapeutic exercise, neuromuscular re-education, or therapeutic activity. Opting for the most accurate code ensures optimal reimbursement, avoiding both missed revenue and unwarranted compensation.

Facing challenges in coding for your physical therapy practice? email us for free consultation!