how to bill for reveiw of physical therapy initial treatment plan

Physical therapists can bill for DME, but they must first obtain a DMEPOS number. As we explain in this post, “Medicare considers physical therapists ‘suppliers,’ but DMERCs won’t see you that way until you obtain this number.” You’ll also need to be sure you pick the right code when billing for DME.

Full Answer

What is a plan of care for a physical therapist?

Medicare states "the plan of care shall contain, at minimum, the following information: diagnoses, long term treatment goals, and type, amount, duration, and frequency of therapy services." The plan of care is established by a physician, non-physician practitioner, physical therapist, an occupational therapist, or a speech-language pathologist.

How do I Bill for physical therapy?

If you’re new to physical therapy, you might be feeling a little overwhelmed by the prospect, so below, we’ve provided some billing basics: To properly bill for your services, you’ll need to include a diagnosis code that demonstrates the medical necessity of your care.

Can a physical therapist Bill the same patient as an OT?

Occupational Therapy Services Simply put, if a service is rendered by an occupational therapist, a physical therapist cannot bill for that service. However, most payers—including Medicare Part B—allow PTs and OTs to bill for services provided to the same patient on the same date of service.

When can therapists bill for re-evaluations?

As for re-evaluations, therapists can bill for the time they spend conducting these mid-POC assessments if “some kind of significant change has taken place regarding the patient’s progress and, therefore, his or her plan of care (POC).” For more detailed guidance on billing for re-evals, check out this blog post. 7.

Can you bill for chart review physical therapy?

The short answer is “yes,” PTs can—and should—account for assessment and management time in their billing and documentation. Yet, as it stands, many PTs don't. And that's a shame—because in failing to do so, they are not only leaving money on the table, but also seriously undervaluing their services.

Which procedure code is used when billing an initial evaluation for PT?

Three codes — 97161, 97162, and 97163 — are used for physical therapy evaluation.

What is the CPT code for re-evaluation of physical therapy established plan of care?

For PT, the new re-evaluation code is 97164 (Reevaluation of physical therapy established plan of care) and will require these components: An examination including a review of history and use of standardized tests and measures; and.

When should I charge my PT re-evaluation?

Under Medicare guidelines, a re-evaluation is medically necessary (and therefore payable) only if the therapist determines that the patient has had a significant improvement, or decline, or other change in his or her condition or functional status that was not anticipated in the POC (emphasis added).

Can you bill 97530 and 97535 together?

Yes, CPT 97535 requires Modifier 59 when two codes are billed individually on the same day. For example the 97535 CPT Code (ADL) and the 97530 CPT Code. CPT 97535 is usually reimbursed after a rate higher than TA, TE, NMR & MT.

Can CPT code 97530 and 97140 be billed together?

Hello, 97140 & 97530 may not be billed together due to they are Mutually exclusive, however a modifier is allowed.

What is the difference between 97161 97162 and 97163?

The new PT codes are: 97161- Low Complexity Evaluation; 97162- Moderate Complexity Evaluation; 97163- High Complexity Evaluation; 97164- PT re-evaluation. Each evaluation level has certain components and are different between PT and OT. PT has four components to each evaluation code and OT has three.

Can 97164 and 97110 be billed together?

That's because CMS—at the behest of the APTA—has agreed to accept these pairs without the use of a modifier. In other words, you can perform the following services—and receive payment for them—without needing to affix modifier 59: 97110 with 97164. 97112 with 97164.

Can 97162 and 97140 be billed together?

Yes. It's possible to bypass the edit by using the 59 modifier/X modifier when billing 97140 with the physical therapy evaluation codes (97161, 97162, or 97163). If you don't use the modifier for this combination of codes, CMS will deny the manual therapy code.

What is a physical therapy reevaluation?

A FORMAL REEVALUATION IS PERFORMED WHEN THERE IS A DOCUMENTED CHANGE IN FUNCTIONAL STATUS OR A SIGNIFICANT CHANGE TO THE PLAN OF CARE IS REQUIRED. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY.

What is difference between progress note and re evaluation?

Re-evaluations are not routine and shouldn't be billed routinely. Progress notes are routine and are completed at every 10th visit or every 30 days (whichever comes first).

What is PT Eval Mod complex 30 min?

Moderate Complexity – Typically, 30 minutes are spent face-to-face with the patient and/or family. High Complexity – Typically, 45 minutes are spent face-toface with the patient and/or family.

What is the CPT code for rehab?

Most of the CPT codes that are relevant to rehab 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.

What is CPT in medical terms?

The American Medical Association (AMA) 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 APTA, “when billing most third parties for services…it is necessary to utilize [CPT] 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.”

How long does it take for a physical therapist to get a POC?

Initial certification: Medicare requires physical therapists to obtain a physician signature on a patient’s POC within 30 days of the evaluation. The initial certification covers the first 90 days of treatment. To continue treatment past the first 90 days, therapists must obtain recertification from the physician.

What is the importance of verifying patient demographics?

Before you submit your bill—actually, before you begin treatment—it’s extremely important that you verify patient demographics and insurance information (including the primary and secondary payers, if applicable). This will help ensure you submit a “clean” claim, which—according to the APTA —is one that is “complete, accurate, and in the case of a paper claim, legible.”

What is defensible documentation?

Defensible Documentation. One of the best ways to support your billing process is to ensure your documentation is defensible. Ultimately, it’ll help you demonstrate medical necessity, so you receive appropriate reimbursements.

What is EMR billing?

Many providers use billing software to prepare and submit their claims—and many electronic medical record (EMR) systems integrate with popular physical therapy billing software to eliminate the double data-entry that can often lead to errored claims. Even better, though, is an EMR that has its own built-in billing software and full-service RCM solution. That way, you know you’re getting the best of all worlds—including the very best support—regardless of whether you choose to handle your billing in-house or outsource it to the experts. For more information on finding the right billing solution, check out this article.

What is a progress note?

A progress note is more like a update or check-in about a patient's treatment. It should include an evaluation of the patient’s progress toward current goals, a professional judgement about continuing care, modified goals and/or treatment (if necessary), and the decision to discharge the patient (if necessary).

What is the BBA for Medicare?

The Balanced Budget Act of 1997 (BBA) was introduced to control Medicare spending. The result was the therapy cap. The bill states that the maximum amount that Medicare will payout in physical therapy costs for the year.

What is the 8 minute rule for physical therapy?

5. The 8-Minute Rule. If you have Medicare, the 8-minute rule is an important part of how your physical therapist submits billing to your insurance.

What to do if you don't want to switch providers?

If you don’t want to switch providers and your physical therapist is out of network, talk to them about their plans to become credentialed. Some physical therapists have a successful practice without the need to be in-network. Others might be waiting for a compelling reason to go through the lengthy paperwork process.

How much does Medicare pay for physical therapy?

With Medicare, you typically pay 20 percent for outpatient therapy for the amount Medicare approves for that year. With Part B, you have to meet your deductible before Medicare will pay anything toward the bill. Part A requires that you are hospitalized before physical therapy costs can be covered by your plan.

What is group therapy?

Group therapy includes the treatment of two or more people in the same session. You don’t have to be doing the same activities during group visits. If each person needs individual attention during a group visit, your therapist will likely bill you for a one-on-one visit.

Is physical therapy billable time?

The time you spend with the therapist is considered billable time. Typically, required breaks aren’t included in this billable time. When your physical therapist calculates this billable time, they will include evaluations and reevaluations of your progress. This includes the initial visit to therapy where a care plan is decided.

When did the therapy cap end?

The therapy cap was removed in 2018, but this doesn’t mean your old medical bills are now automatically covered. You can appeal decisions on past medical bills of up to $2,080. These bills must be for speech, physical or occupational therapy. Appeals are handled by the targeted medical review board.

What is the CPT code for massage therapy?

3. Therapeutic Massage. It’s always important to check your state practice act, but in most cases, physical therapists can bill CPT code 97124 (massage therapy) when they provide therapeutic massage.

What is Medicare code 97763?

97763: Orthotic and Prosthetic Management. For Medicare, therapists should use L-codes, which “are the HCPCS codes providers must use when billing for splints, braces, and any other services related to assessment, fabrication, and supplies—including follow-up.”. 6.

Can PTs provide virtual services?

As of the publication date of this article , many states have allowed PTs to provide virtual services—if only temporarily. Furthermore, CMS has provisionally added PTs to its list of telehealth-eligible providers for the duration of the public health emergency period. On the commercial insurance side, many payers allow PTs to bill for telehealth services—some of which have had that policy in place since before the pandemic. Ultimately, you should check both your state practice act as well as each individual payer’s current rules regarding telerehab before you provide any virtual services.

Can a therapist bill for dry needling?

Furthermore, “Therapists should never bill beyond what they would normally bill in the absence of student assistance.”. 8. Dry Needling. While PTs can often bill for dry needling services, it ultimately depends on the state’s—and the payer’s—rules.

Does Medicare pay for therapists?

According to this CMS document, “Medicare pays only for skilled, medically necessary services delivered by qualified individuals, including therapists or appropriately supervised therapy assistants. Supervising patients who are exercising independently is not a skilled service.” It is safe to assume that most private payers adhere to this same rule.

Can a physical therapist bill for a physical therapy appointment?

Simply put, if a service is rendered by an occupational therapist, a physical therapist cannot bill for that service. However, most payers—including Medicare Part B—allow PTs and OTs to bill for services provided to the same patient on the same date of service.

Can a physical therapist bill for DME?

Physical therapists can bill for DME, but they must first obtain a DMEPOS number. As we explain in this post, “Medicare considers physical therapists ‘suppliers,’ but DMERCs won’t see you that way until you obtain this number.”. You’ll also need to be sure you pick the right code when billing for DME.

How long does it take to get a verbal order from Medicare?

A therapy provider, per Medicare rules, may obtain a verbal order for certification or recertification of the plan of care; however, the verbal order must be signed and dated by the physician/non-physician practitioner within 14 calendar days.

How soon after a plan of care is established should it be certified?

The certification of the plan of care should occur as soon as possible after it is established or within 30 calendar days of the initial therapy treatment. Payment may be denied if the physician does not certify the plan of care; therefore, the therapist should forward the plan to the physician as soon as it is established.

How often do you need to recertify a plan of care?

Recertification of the plan of care, which also requires a physician or non-physician signature and date, should occur whenever there is a significant change in the plan or every 90 days from the initial plan of care certification.

What is a plan of care for rehabilitation?

What is a Plan of Care. Outpatient rehabilitation therapy services must relate directly to a written treatment plan (also known as the plan of care or plan of treatment). Medicare states "the plan of care shall contain, at minimum, the following information: diagnoses, long term treatment goals, and type, amount, duration, ...

Do you have to have a plan of care before therapy?

The plan of care must be established before the therapy treatment can begin. Establishing the plan of care is different than certifying the plan of care. Medicare states that certification of the plan of care requires a dated signature on the plan of care, or some other document, by the physician or non-physician practitioner who is ...

Who establishes a plan of care?

The plan of care is established by a physician, non-physician practitioner, physical therapist, an occupational therapist, or a speech-language pathologist. The signature and professional identity of the person who established the plan of care and the date it was established must be documented within the plan of care.

How often do you need to recertify a plan of care?

Recertification of the plan of care, which also requires a physician or non-physician signature and date, should occur whenever there is a significant change in the plan or every 90 days from the initial plan of care certification.

How long does it take to get a verbal order from Medicare?

A therapy provider, per Medicare, may obtain a verbal order for certification or recertification of the plan of care; however, the verbal order must be signed and dated by the physician/non-physician practitioner within 14 calendar days.

How soon after a plan of care is established should it be certified?

The certification of the plan of care should occur as soon as possible after it is established or within 30 calendar days of the initial therapy treatment. Payment may be denied if the physician does not certify the plan of care; therefore, the therapist should forward the plan to the physician as soon as it is established.

What is outpatient rehabilitation?

Outpatient rehabilitation therapy services must relate directly to a written treatment plan (also known as the plan of care or plan of treatment ). Medicare states “The plan of care shall contain, at minimum, the following information: diagnoses, long term treatment goals, and type, amount, duration, and frequency of therapy services.”.

Who is required to sign a Medicare plan of care?

Medicare states that certification of the plan of care requires a dated signature on the plan of care, or some other document, by the physician or non-physician practitioner who is the primary care provider for the patient.

Who establishes a plan of care?

The plan of care is established by a physician, non-physician practitioner, physical therapist, an occupational therapist, or a speech-language pathologist The signature and professional identity of the person who established the plan of care and the date it was established must be documented within the plan of care.

Why is billing for every minute of a patient visit a red flag?

In fact, billing for every single minute of a patient visit would be a serious red flag, because it would be nearly impossible for a therapist to run an entire session of pure, continuous billable time.

How many billable minutes should I record?

Remember, when it comes to recording treatment time, almost doesn’t count; in other words, if you provided a particular timed treatment for 14 minutes, that’s how many billable minutes you should record. “Both treatment times and session times should be recorded to the exact minute,” this article states.

What should a therapist indicate in a soap note?

As for the documentation aspect, the therapist should be able to indicate the total visit time in the SOAP notes and also indicate the total direct time spent on each intervention. (If the therapist uses WebPT, there's actually a specific area in the SOAP note to make this distinction.)

How many units are in 40 minutes?

With that in mind, your total timed minutes (40 minutes) are equivalent to three (3) units (i.e., two 15-minute increments with a remainder of 10 minutes). You would then only bill one unit for the untimed code, which brings you to a total of four units.

Is documentation time considered billable time?

Unfortunately, you won’t get paid for that effort, because as Pauline Watts, MCSP, PT, and Danna D. Mullins, MHS, PT, explain in this article, “Documentation time alone is not considered billable time under Medicare regulations.”.

Is documentation time billable for Medicare?

Documentation takes time—there’s no denying that. Even if you have an EMR system that streamlines the process, there’s still a lot of effort that goes into creating notes that are complete, correct, and compliant. Unfortunately, you won’t get paid for that effort, because as Pauline Watts, MCSP, PT, and Danna D. Mullins, MHS, PT, explain in this article, “Documentation time alone is not considered billable time under Medicare regulations.” The key word, however, is “alone”; the article goes on to explain that in some cases, you may be able to provide billable services at the same time you are documenting. Case in point: patient education, which includes any time dedicated to “discussing progress in therapy with the patient, including improvement in objective measures and how they are progressing toward their goals,” Watts and Mullins write. “If we are documenting this patient education information at the same time we are providing it to the patient, then this documentation time can be included in the treatment time.” One major caveat: the patient must actively participate in the conversation. That is, he or she cannot just sit passively and listen as you read or dictate your notes out loud. “Obviously not all documentation can be done in this manner and not all patients are appropriate to include in this educational process,” Watts and Mullins continue. “ [But the] practice of sharing the information with the patient has many extremely positive outcomes for the patient.”

How long can you bill for a 15 minute treatment?

Now, per Medicare’s 8-minute rule, you can bill for a full 15-minute timed treatment unit as long as you provided that service for at least 8 minutes, but as this blog post explains, it’s still imperative that you record the exact duration of each type of treatment you provide. 6.

What is an unanticipated discharge?

In the case of an unanticipated discharge (e.g., the patient stops showing up for therapy or self-discharges), the therapist may base any treatment or goal information on the previous treatment notes or the verbal reports of a PTA or other clinician.

What is discharge summary?

Functionally, a discharge summary (a.k.a. discharge note) is a progress note that covers the reporting period from the last progress report to the date of discharge. The discharge summary is required for each episode of outpatient therapy treatment.

What information is needed for physical therapy?

Physical therapists, on the other hand, are solely responsible for noting the following required information: 1 assessment of patient improvement or progress toward each goal; 2 decision regarding continuation of treatment plan; and 3 any changes or additions to the patient’s therapy goals.

How often do you need to report progress on Medicare?

Per the Medicare Benefit Policy Manual, “The minimum progress report period shall be at least once every 10 treatment days. The day beginning the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation, reevaluation or treatment.

What is progress note?

According to Mosby’s medical dictionary, progress notes are “notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient’s condition and the treatment given or planned.”.

Can a physical therapist complete a Medicare discharge summary?

Similar to progress reports, only a licensed physical therapist may complete a Medica re discharge summary—which makes sense considering that a discharge summary is technically a progress report.

Do you have to sign a discharge document?

To answer your question, no, a discharge document does not need to be signed by the patient's physician. That being said, some physicians may request you send them a copy of the discharge summary once the patient has been discharged from your care, but this is not a Medicare requirement.

Introduction

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What Are The Codes?

What’s The Terminology?

What’s The Process?

Codes

• ICD
  To properly bill for your services, you’ll need to include a diagnosis code that demonstrates the medical necessity of your care. This code—or codes—will come from the latest version of the International Classification of Diseases code set, ICD-10. According to the American Physical Th…
• CPT
  The American Medical Association (AMA) 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 APTA, “when billi…

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Terminology

Forms

Process

Software Or Service

Verification

Copayment Collection

Abns

Defensible Documentation