how to bill for reveiw of physical therapy 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

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.

Can a therapist Bill for billable time in rehab therapy?

Unfortunately, the rules governing billable time in rehab therapy are not as, shall we say, open to interpretation. 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.

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.

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).

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.

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 you bill 97530 for evaluation?

As of January 1, 2020, the National Correct Coding Initiative (NCCI) has stated that you cannot bill an initial evaluation along with CPT code 97530 (therapeutic activities) and/or 97150 (group therapy) on the same date of service for the same patient.

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 97530 and 97112 be billed together?

You will not be able to use a 59 modifier to charge 97530 with an initial evaluation. Note that you can continue to bill other timed codes, such as 97110, 97112 and 97140 with an initial evaluation. However, you will now be required to use a 59 modifier if you bill 97140 (manual therapy) with an initial evaluation.

What modifier should be used with 97530?

59 modifierWhen using the 59 modifier, you are indicating to the insurance company that each service was medically necessary and performed independently of the other. One typical example of when to use this modifier is if you bill for manual therapy (97140) and therapeutic activities (97530), in the same session.

Can physical therapists Bill 97535?

Services that started as of March 1, 2020, and are provided for the duration of the public health emergency are eligible. These CPT codes are eligible to be billed: 97161- 97164, 97110, 97112, 97116, 97150, 97530, 97535, 97542, 97750, 97755, 97760, and 97761. Patients may be either new or established.

Can PT and OT Bill 97530 on the same day?

The new mandate from CMS prohibited the use of CPT codes 97530 (therapeutic activities) and 97150 (therapeutic procedures, group, two or more individuals) on the same day as an initial PT or OT evaluation.

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.

Does CPT code 97530 require a modifier?

There are three steps you must follow to get paid. 97530 CPT code is often invoiced using procedure code CPT 97140 (manual therapy techniques) and modifier 59 to avoid CCI changes. For example, movement exercises can target a particular body part or the complete body.

What is the difference between 97110 and 97530?

If only one outcome is intended by the exercise, CPT code 97110 should be used. Where more than one outcome is expected using balance boards, fitness balls, stretch bands, etc. where increased motion, flexibility, strength and/or improved proprioception is intended, CPT code 97530 should be used.

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.

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 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.”

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.

Can you call the payer before you submit a claim?

To ensure you choose a code that’s reimbursable under your payer’s payment policy, you can always call the payer before you submit a claim . According to the APTA, “Your goal is to maximize the number of claims that are paid on the first submission and to minimize the need for appeals.”. So, when in doubt, ask.

Do payers accept paper claims?

Forms. Most payers—and providers—prefer to bill using electronic claim forms. However, some payers do still accept paper claims. According to the APTA, the most common form is the Universal Claim Form ( CMS 1500 ), although some payers may have their own.

Can you submit a bill to a third party payer?

Per the APTA, once you provide your services, you’ll submit a bill to either your patient or a third-party payer. In some cases, however, you may actually provide the billing information to a claims clearinghouse that will then prepare your bill on your behalf.

General Information

CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Article Guidance

Therapy evaluation and formal testing services involve clinical judgment and decision-making which is not within the scope of practice for therapy assistants.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.

How many minutes are allowed in a therapy session?

The 8-Minute Rule: The 8-minute rule is critical for therapists to understand because, according to American Medical Association (AMA) guidelines, leftover minutes that fall into multiple categories with less than 8 minutes per category cannot be billed for.

Why do you become a physical therapist?

You became a therapist to help people improve the quality of their life, however you can’t assist those in need for long if you don’t make enough money for your practice to survive and grow. The billing process is probably the least liked task for physical therapists, yet one that cannot be ignored.

How many characters are in a CPT code?

CPT codes consist of 5 characters, with the majority of codes being numeric, however, some codes have a fifth alpha character. There is a code assigned for every service or procedure, as well as “unlisted codes” for those services and procedures not specifically named in another defined CPT code. Because there are such a large number ...

What is the CPT category I?

Because there are such a large number of services and procedures, the AMA organized CPT codes into three category types: CPT Category I – This contains the largest body of codes. It consists of those commonly used by providers to report their services and procedures (most CPT codes will be Category I codes).

What is CPT medical?

a registered trademark of the American Medical Association (AMA), is a medical code set that is used to report a medical, surgical or diagnostic procedure and services to entities such as physicians, health insurance companies and accreditation organization s.

What is the CMS-1500 form?

Therapists will normally use the CMS-1500 form or the 837P electronic format to submit claims to Medicare contractors for Medicare Part B-covered services (the current 1500 claim forms accommodate ICD-10 codes). Outpatient and partial hospitalization facility claims might be submitted on either a CMS-1500 or a UB-04, depending on the payer.

What is a GP modifier?

The GP Modifier indicates that a physical therapist’s services have been provided. The GP Modifier is commonly used in inpatient and outpatient multidisciplinary settings.

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 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.

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.

General Information

CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.

Article Guidance

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Outpatient Physical and Occupational Therapy Services L34049.

ICD-10-CM Codes that DO NOT Support Medical Necessity

The following ICD-10-CM Codes do not support the medical necessity for the CPT/HCPCS code 97035.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.

Should providers avoid prolonging unwarranted treatment?

Strong says providers should avoid prolonging unwarranted treatment to simply increase revenue. “Proper utilization is critical in today’s market, especially in physical medicine where reimbursement caps are common in Medicare, some network organizations, and some commercial carriers,” he adds.

Can a provider bill more than one patient at the same time?

Providers shouldn’t bill a time-based code for more than one patient at the same time unless they can show the services were performed during separately intervals and/or with the help of a PT or OT assistant who is a reimbursable provider under the payer contract, says Strong.

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, ...

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 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.

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.

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 ...

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.

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.)

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.”

Can a therapist bill Medicare?

Most payers, including Medicare, allow therapists to bill for the initial evaluations necessary to establish plans of care. (However, please note that, according to this ADVANCE article, therapists billing under Medicare Part A in a skilled nursing setting cannot bill for the “time it takes to perform the formal initial evaluation and develop the treatment goals and the plan of treatment cannot be counted as minutes of therapy received by the beneficiary.”)

Can you bill for unskilled prep time?

1. You can’t bill for unskilled prep time. Medicare reimburses for skilled time only. Thus, any unskilled time dedicated to preparing a patient or treatment area for therapy cannot be counted as billable time, even if you, the licensed therapist, are completing those tasks.

How to get a POC?

A POC being sent for certification must contain ALL of the following elements to meet the requirements: 1 The date the plan of care being sent for certification becomes effective (the initial evaluation date is acceptable) 2 Diagnoses 3 Long term treatment goals 4 Type, amount, duration and frequency of therapy services 5 Signature, date and professional identity of the therapist who established the plan 6 Dated physician/NPP signature indicating either agreement with the plan or any desired changes.

What are the requirements for a POC?

A POC being sent for certification must contain ALL of the following elements to meet the requirements: The date the plan of care being sent for certification becomes effective (the initial evaluation date is acceptable) Diagnoses. Long term treatment goals. Type, amount, duration and frequency of therapy services.

How long can a Medicare plan of care be certified?

The maximum length of time any certification period used to be 30 days, however now it can run up to 90 days.

What happens if you don't comply with Medicare?

If, in the course of the audit, they find you do not have the Certifications/Re-certifications, if appropriate, included in the chart they can deem your care for that patient as not meeting the medical necessity or the requirement to be under a physician’s care. In that case Medicare can decide that all the care for these patients should not have been carried out and can ask for all payments plus interest and a penalty to be returned to them. This can come to a significant amount of money, especially if it occurs in a number of patient’s charts.

Can a physical therapist establish a POC?

CMS says either a physician/NPP or physical therapist can establish the POC but if the therapist does it then physician/NPP must approve of the plan. That’s where the signing off on the plan of care by the physician/NPP affirms that the patient is under their care and they agree with the plan.

Can you claim all your patients require the maximum time allowed?

Claiming all your patients require the maximum time allowed may trigger an audit of your documentation. CMS recommends you set the duration for your certifications at your best estimate of the length of time it will take your patient to achieve their goals.

Can Medicare ask for all payments plus interest?

In that case Medicare can decide that all the care for these patients should not have been carried out and can ask for all payments plus interest and a penalty to be returned to them. This can come to a significant amount of money, especially if it occurs in a number of patient’s charts.

Introduction

See more on webpt.com

What’s The Terminology?

What Are The Forms?

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…

See more on webpt.com

Terminology

Forms

Process

Software Or Service

Verification

Copayment Collection

Abns

Defensible Documentation

Article Summary

Breaking Down The Codes

• The International Classification Of Diseases
  Codes can be confusing and irritating, but they are necessary in order successfully bill for your services. Diagnosing your patients’ conditions in a way that breaks down the medical necessity of those services is accomplished by way of the International Classification of Codes (ICD), which …
• The Current Procedural Terminology
  CPT. a registered trademark of the American Medical Association (AMA), is a medical code set that is used to report a medical, surgical or diagnostic procedure and services to entities such as physicians, health insurance companies and accreditation organizations. In other words, it is a l…

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The Use of Modifiers

Understanding The Terminology

Forms to Use

Choosing A Software

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