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cpt manual therapyThe difference is that on claim forms, CPT codes identify services rendered rather than patient diagnoses. All rights reserved. In short, CPT codes are procedure codes and ICD-10 codes are patient diagnosis codes. Then, you might complete standard canalith repositioning on your patient, in which case you would include CPT procedural code 95992 on your claim. Commercial payers often allow rehab therapy providers to deliver and receive reimbursement for “true” telehealth services, and as of April 30, 2020, Medicare has authorized PTs, OTs, and SLPs to provide and bill for telehealth for the remainder of the COVID-19 emergency response period. In most cases, therapists bill for “true” telehealth services using the same CPT codes they would bill for services provided in the clinic (typically with some type of telehealth modifier affixed to the claim, per the individual payer’s guidelines). How do I use it? Please note that while some Medicaid programs, commercial payers, and Medicare Advantage payers may follow suit, this change does not necessarily affect them, so be sure to reach out to your other payers to determine where they stand. Learn more here. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.” But that’s because modifier 59 is intended mainly for surgical procedures, so the definition leans a great deal that way. If you’re providing two wholly separate and distinct services during the same treatment period, it might be modifier 59 time. The National Correct Coding Initiative (NCCI) has identified procedures that therapists commonly perform together and labeled these “edit pairs.” Thus, if you bill a CPT code that is linked to one of these pairs, you’ll receive payment for only one of the codes.http://www.sdds.be/userfiles/dx4831-01e-manual.xml

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It’s therefore your responsibility as the therapist to determine whether you’re providing linked services or wholly separate services. This, in turn, determines whether modifier 59 is appropriate. According to NCCI in July 2020, the following are considered linked services when billed in combination with 97140: 95851, 95852, 97018, 97124, and 97530. So, if you bill any of these codes with 97140, you’ll receive payment for only 97140. Medicare actually uses this example on its site to explain appropriate use of modifier 59 among rehab therapists. This means that you cannot report the two codes together if you performed them during the same 15-minute time interval. The same holds true for billing 95851, 95852, 97018, and 97530. However, you can never bill 96523 or 97124 with 97140, because these codes represent mutually exclusive procedures. Perhaps that’s because the CPT Manual doesn’t offer the most helpful guidance. Therefore, we recommend asking the following questions to decide if and when you should use modifier 59. Recognizing those instances, though, requires you to recognize NCCI edit pairs. To make a long story short, edit pairs—also called linked services—are sets of procedures that therapists commonly perform together. If you submit a claim containing both of the codes in an edit pair, you’ll only receive payment for one of the procedures, because the payer will assume that one of the services was essentially “built into” the other. But what if—for whatever reason—you actually didn’t perform those services together. That’s where modifier 59 comes into the picture. Basically, when you append modifier 59 to one of the CPT codes in an edit pair, it signals to the payer that you provided both services in the pair separately and independently of one another—meaning that you also should receive separate payment for each procedure. It’s on you to fill in the plot holes with detailed, defensible documentation.http://bkkgroup.by/var/upload/dx4win_manual.xml After all, your documentation justifies your billing decisions—and if you’re ever faced with an audit, your notes will be your main source of proof that those decisions were the right ones. That means you should never: So, next you’d ask: Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.” Modifiers XE, XP, XS, and XU are intended to bypass a CCI edit by denoting a distinct encounter, anatomical structure, practitioner, or unusual service. However, even though these modifiers went into effect January 1, 2015, the APTA has stated that therapists do not need to use them in place of modifier 59—at least not yet. That being said, therapists may be required to use the new modifiers in the future, so keep an eye—or an ear—out for further instruction regarding modifier 59 usage. Here’s how to use the chart: Most government payers—like Medicare, Tricare, and Medicaid—use this same list. However, private payers often create their own edit pairs; therefore, there is no guarantee they will pay, even with an applied modifier 59. Enter your email address, and we’ll send it your way. That’s because these codes have been replaced by a new set of eight evaluative codes: two for re-evaluations and six for evaluations. That’s because the new codes for initial evaluations are tiered according to the complexity of the evaluation performed. So, PTs and OTs now must determine whether a patient evaluation is low complexity, moderate complexity, or high complexity—and then select the CPT code that correctly represents that level of complexity. Here’s a brief breakdown of the new codes: Check out this blog post, this blog post, and this webinar. Keep reading for three example scenarios to help you make what can occasionally be a challenging decision (adapted from this post by WebPT’s Kylie Mckee). For several more examples, check out the post in full. For example, if a high-school soccer player is receiving care for left patellofemoral pain syndrome and develops similar symptoms in his or her right knee, then you would perform (and bill) for a re-eval and update the existing plan of care. After all, as Mckee explains, “a re-evaluation is triggered by a significant clinical change in the condition for which the original plan of care was established.” The patient should now be receiving care for bilateral patellofemoral pain syndrome. After all, “The second, unrelated problem (i.e., with a different body part or body system) may not, in and of itself, result in a change to the original condition.” McKee cautions that there isn’t a whole lot of formal guidance on how to handle this scenario, but if it’s been 60 days since the patient received care from you, Medicare requires you to begin a new case. And because you’ve already discharged the patient, it makes sense that you would start over if that patient say, reinjures his or her left rotator cuff and needs your services again. For commercial payers, though, you should defer to the payer’s rules—and, as always, your state practice act. In fact, you should only ever bill for a re-evaluation if one of the following situations apply: We’ve also written a summary of final rule changes affecting rehab therapists. You can read that here. We know Medicare regulations, including all applicable modifiers, backwards and forwards. Click the button below to schedule a free online tour of WebPT, and we’ll show you how we help ensure regulatory compliance, so you get paid and avoid penalties. Read on for a detailed breakdown and download the guide! We physical therapists receive compensation for our services depending on how we bill using these CPT codes. If we don’t properly bill for our services provided, we could be losing out on valuable income. This article aims to be a useful resource for any PTs using physical therapy CPT codes. I initially wrote this article in 2016 at the beginning of my career in the field of physical therapy. At the time, I had no idea just how popular the article would become (over 45,000 views as I write this sentence!). In school, we do not learn much, if anything at all, about using CPT codes properly and maximizing reimbursement. However, we are all expected to do so when we begin working. The climate for outpatient PT practice is changing quickly, and so it is more important than ever that we as clinicians understand how to use these codes properly in order to protect our profession and keep our practices thriving. Since writing this article, I have taken on roles as supervisor and clinic director. These are positions that require a superior knowledge of this subject matter. I've made some edits to this article to help you understand billing procedures with a little more clarity. Check out our quick guide to telehealth billing and reimbursement for physical therapy! The payment we receive for our services is based on the resource-based relative value scale (RBRVS), which takes into consideration the work performed, the expense to the practice, and the liability and risk in providing the services or procedures. Now, I don’t know about you, but I sure didn’t learn much about proper billing when I was in PT school. This is one of the topics that we are expected to learn on our own as we embark on our clinical affiliations and careers. Depending on the physical therapy setting in which you practice, and the site in which you are placed, you will find that people have different opinions on what constitutes proper use of these physical therapy CPT codes. The Billing Black Hole I remember my first few months of trying to figure out how to properly bill in order to please the insurance companies and to meet my own clinic’s expectations. It was odd to me that there was so much widespread uncertainty involved in such a vital part of what we do on a daily basis as clinicians. How could this topic be so sensitive and debatable. Don’t insurance companies want to clearly define what procedures they will be paying for. How will I know how to bill for my patients’ time in the clinic if I don’t truly understand what the codes even mean. Those tasked with the job of creating and modifying Medicare legislation and reimbursement must have some idea of what they are doing. Payable criteria for each billing code must remain vague and undefined in order to give the insurance company the power to deny our claims if they feel our services aren’t necessary or warranted. To them, if a patient is considered “functional,” they no longer require skilled physical therapy intervention. When it comes down to it, insurance companies are businesses. Their main job isn’t to provide affordable, high quality healthcare services to all who sign up for their services. Rather, their goal is to turn a profit. The net profit of the industry over the past 10 years has equaled almost half a trillion dollars. Knowledge Is Power When It Comes to Physical Therapy CPT Codes It would be fruitless to spend our valuable emotional energy struggling with the false idea that everyone who needs quality care will get the necessary funding from their insurance companies, especially since our patients already require so much of this energy on a daily basis. We need to be informed of how to properly bill for our services to ensure small business success. We need our private practice clinics to thrive so that they may continue to serve our communities and the patients who need us. We owe it to our profession to be knowledgeable about how to properly and legally submit claims for our services. The future of reimbursement for physical therapy services may depend on it. Know Your Value For the reasons mentioned above, we must make sure that we write a fairly detailed description of the interventions that fall under each billing code we are using to submit our claims. We must be able to make an argument for what we are doing with our patients so that the insurance company sees we are providing high quality care for our patients and aren’t just trying to receive as much money as possible. We must use the vague and barely defined codes to our advantage. I know this sounds tough now that many of our clinics have been forced to increase patient volume in an effort to combat decreased reimbursement rates across the board, but the extra effort is worth it. The truth is that we are underpaid for what we provide. We have a doctoral level of education. Let’s show the insurance companies how much we know and how valuable our skill set is. Don’t let low insurance reimbursement dictate your self worth as a healthcare provider. Nobody else can provide the service we provide. Simplifying the Billing Process The main purpose of this article is to not only provide some insight on proper use of physical therapy CPT codes, but to spark some debate on the topic among providers. I want us to air out our frustrations and help each other understand the topic by providing personal accounts and information regarding what these codes mean and the criteria for which they should be utilized. While the topic of billing can be complex, the focus of this particular article is to provide basic information every physical therapist should know about using these billing codes. Billing Terminology In this section, I am going to outline some of the billing terminology that is useful in order to understand how to use physical therapy CPT codes. We've broken it down even further. These codes can only be billed once per treatment session. The time spent providing these services cannot be included in your calculations of timed units and are considered separate billing codes. Timed codes: These codes are based on the time spent one-on-one with the patient and include only skilled interventions. This time includes the pre-treatment, actual treatment, and post-treatment time. Pre-treatment time: Includes assessment and management, assessing patient progress, inspection of the tissue or body part, analyzing results of the previous treatment, asking questions, and using clinical judgment to establish the day’s treatment. All of the contact time is administered by the PT or PTA. Intra-treatment time: Time spent providing the intervention. Post-treatment time: This includes time spent analyzing the patient’s response to intervention, educating the patient, giving advice, providing documentation, or communicating with other healthcare professionals on the patient’s behalf. The patient must be present during this period of time in order to include it in the time calculation. Medicare 8 Minute Rule: Rule of mixed remainders: This is where things tend to get confusing. Try this example: You just spent 24 minutes on exercises in which you billed 1 unit of therapeutic exercise and 1 unit of neuromuscular re-education. Now let’s say you spent an additional 7 minutes performing manual therapy and another 4 minutes using iontophoresis. According to Medicare guidelines ( 8 Minute Rule ), you can combine this extra time (11 minutes total) into one additional unit of manual therapy since the sum of your remainders was more than 8 minutes (you bill for the service that you provided more of, hence, manual therapy in this case). However, 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. This is why it is important to know which insurance company follows what guidelines. Now that we’ve got some of the important details out of the way, let’s start talking about what I believe constitutes each of the used physical therapy CPT codes. I have done extensive research on the topic, only to find that not much information actually exists. I will be basing the information on my research, what I feel makes sense to me, and what I have learned from coworkers and clinical instructors in the past. Ambulation for endurance training would be included in this category (not gait training!). Most of the time, people use this code because it feels like the safe bet, however, the intervention performed fits better under the code for therapeutic activity. Therapeutic Activity tends to receive a higher reimbursement rate from insurance companies than therapeutic exercise does, even if it is only a few dollars more (it adds up over the course of a year!). Therapeutic exercise typically does not require as much skill as therapeutic activities or neuromuscular re-ed does, which may be a reason why the reimbursement is lower. You would include time spent kinesiotaping in this category as well as performing stabilization exercises, facilitation or inhibition, desensitization, ergonomic training, improving motor control, and plyometrics. Foam rolling, for instance, may be included in this category if used for desensitization of a painful region or to facilitate muscle contraction prior to performing exercise. Any activity that requires high-level coordination and cueing may fall in this category since we are attempting to re-train neuromuscular output. 97116 Gait Training: Includes sequencing, training using a modified weight-bearing status, employing assistive devices, and completing turns with proper form. If you are using this code, make sure you are focusing on the biomechanics of the gait cycle in some form or another. Having a patient walk in order to improve cardiovascular health is not considered gait training. 97140 Manual Therapy: Includes soft tissue mobilization, joint mobilization, manipulation, manual traction, muscle energy techniques (performed using resistance applied by PT), and manual lymphatic drainage. Manual resistive exercise can be included in this category or in therapeutic exercise since it requires that resistance be applied by the therapist and may be performed with the goal of improving strength or endurance. You can also consider muscle energy techniques as part of the neuromuscular re-education code. Manual therapy is typically reimbursed at a lower rate than therapeutic exercise, neuromuscular re-ed, and therapeutic activities. Remember, we are not massage therapists. We are most skilled in exercise prescription and load management. That being said, manual therapy techniques that compliment a well-thought-out exercise program can be very effective. I’d suggest you try not to build a dependency on it. 97150 Group Therapy: PT provides therapeutic procedure to two or more patients at the same time on land or in an aquatic setting. It requires constant attendance by the PT or PTA but not one-on-one time. Medicare requires information about the type of group and number of participants in it. If you see multiple Medicare patients at one time, this is the code you should be billing for. Naturally, the reimbursement rate would be less than if the patient was treated one-on-one. An example of group therapy may be a Parkinson’s Disease group exercise class or a “back school” program for people with chronic low back pain. 97530 Therapeutic Activities: Includes “dynamic activities” that are designed to improve functional performance. This code is reimbursed at a higher rate than therapeutic exercise, which is most likely due to the fact that these activities require a higher level of skill and repetition in order to achieve mastery. The six basic ADLs are: Eating Bathing Dressing Toileting Transferring Continence As long as you are working on any of these activities with your patient’s exercise program, you can bill this code. You should not be reporting that your treatments are focused on any of these ADLs if the patient has no problem with performing them or if you already included them in the count for your other codes. Teaching a home exercise program that focuses on improving ROM, flexibility, strength, or endurance falls under the therapeutic exercise code. This code is typically reimbursed at a higher rate than TA, TE, NMR, and MT. This is due to the fact that you cannot teach self-care with a “hands-off” approach. You must be actively lecturing, demonstrating, and providing literature in order to appropriately perform the tasks required by this CPT code. 97750 Physical Performance Test or Measurement: Includes tests determining function of one or more body areas or measuring an aspect of physical performance including a functional capacity evaluation. A written report must be attached if you are to bill for this code. Strapping can be defined as a procedure involving adhesive strips that promote structure or stability to a joint. Use of McConnell taping techniques that provide added stability, immobility, or promote comfort in the patient may warrant usage of these codes. Some feel that strapping is provided with plaster pieces instead of tape, however I have not come across literature that supports this idea. I will say with confidence that kinesiotaping techniques that promote movement would not fall under this category. McConnell tape is a more rigid, stabilizing tape and would be more appropriate. Kinesiotape should be used with the neuromuscular re-ed code. 90901, 90911 Biofeedback: “ Biofeedback therapy is a type of behavioral technique by which information about a normally unconscious, physiologic process is presented to the patient and is demonstrated by a signal to educate the patient for an optimal muscle response. Biofeedback therapy is covered under Medicare only when it is reasonable and necessary for the individual patient for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness; and more conventional treatments (heat, cold, massage, exercise, support) have not been successful. This therapy is not covered for treatment of ordinary muscle tension states or for psychosomatic conditions.”- CMS.gov This procedure is commonly used in the pelvic floor arena to aid in retraining of deep muscles to promote continence. It is also used for neuromuscular control of deep cervical flexors and the deeper lumbar stabilizers. This is an untimed code, so no matter how much of this technique is used you may only bill it once. I’ve seen this procedure performed with a modified blood pressure cuff or bladder for external purposes. Contrary to popular belief, this does not mean that they will pay you the same amount no matter how much you bill. You still need to bill for a certain amount of time in order to reach this capped maximum payment for that day. Make sure you bill for the services you provide your patient and nothing less (or more). Overusing certain codes: Insurance companies pay attention to how often providers use each billing code. If they feel that a provider uses one particular code way more frequently than other providers they deal with, they may place that provider under review (audit). Under-timing the treatment session: The time we calculate for the service we provide should include pre-treatment time, intra-treatment time, and post-treatment time. Please refer to the definitions listed earlier in this article. Using the wrong codes: This one may sound obvious, but consider this: You can make the argument that almost any exercise a patient performs can fall under the code therapeutic exercise. While this may be true, the exercise may be better suited under neuromuscular re-education or therapeutic activity. This is important because payers will typically reimburse higher rates for these two codes than they will for therapeutic exercise. Don’t leave money on the table, but also do not stretch the truth in order to receive unwarranted compensation. What questions do you have about billing. Do you disagree with any of the information above. Would you like to further discuss how we should be using these codes. Please comment below. If you are looking for more information on this topic, check out The Coding and Payment Guide for the Physical Therapist by Optum 360. Retrieved June 15, 2017, from Insurance Company Profitability. (2015, December 03). Retrieved June 15, 2017, from Medicare vs AMA Billing Guidelines. (2015, November 25). Copyright American Medical Association. All rights reserved. When performing manual therapy, make sure that you're performing this service to a separate anatomic region than you are performing a chiropractic manipulative treatment.An example of a direct functional goal would be “able to bend over to tie shoes by himself within two weeks.” Depending on the carrier, when billing procedure code 97140 you must append a modifier. With most payers the -59 modifier is the most widely accepted modifier to signify that a separate and distinct service was performed in a separate anatomic site. Additional information can be found in the CMS Modifier 59 Article here. The KMC University Library has helpful Fact Sheets and Tutorials on how to properly report and code timed codes. If applicable, use diagnosis pointers in box 24E of your 1500 Claim Form to indicate which diagnosis is related to which distinct service. For example, you may point your cervical CMT code (98940) to your cervical diagnosis and your manual therapy code (97140) to your lumbar diagnosis. When these procedures are billed together, the modifier “-59” is used to communicate that independent procedures that are not normally billed together were performed and medically necessary under the circumstances. Be sure to send your well-documented notes as well as the information concerning the ACA’s stance on the use of code 97140. Remember, you don’t have to know everything when you know the people who do. Let us protect you. This website needs javascript in order to function properly!But one of the most glaring differences is the difference in payment between the two. In this article, we’ll be discussing what each of these treatments entail, and how you can go about billing them. Click here to read about it. For manual therapy (CPT 97124), the AMA states that it must include one or a combination of the following: joint mobilization and manipulation, manual traction, soft tissue mobilization, or compression bandaging. Thus, if you want to invoice either of these CPT codes, your documentation must specifically cite the above techniques. You should never bill a code simply because it yields a higher payment. Doing this is a sure-fire way to land yourself in hot water. For more content related to Medicare, please visit Gawenda Seminars and Consulting. Mark Sanna, D.C.Since that time In clinical practice, along with joint mobilization, manual traction, and myofascial Nimmo technique, Some practitioners have been unclear about how to appropriately The Center for Medicare They should Now chiropractors must be paid for neuromuscular Separate Anatomic Sites According to the NCCI correction, when the same provider performs manual therapy In addition, there are Item 21: The Diagnosis CMS 1500 insurance claim forms are printed in red because they are optically As previously stated, when performing 97112, 97124, or 97140, with an adjustment, This is indicated If your billing software automatically defaults For example, if a massage therapist The second definition of a separate encounter is that the same provider performed Counting 15-Minute Intervals In addition to the rules governing who can perform manual therapy and when it Manual therapy is a timed The time spent greeting a patient You must document Manual Therapy Modifiers There are two important modifiers that require your attention when performing First, the codes The 59 modifier When a timed procedure, such as manual therapy is not completed for a complete You must add a second If, for example, only 7.5 minutes of Manual Therapy were Remember that Make the appropriate changes Is it just to April 1, 2002, or can you go Each state has its It could vary from 2-5. In my opinion, any other code is questionable and should be avoided unless the user has certifications that have specified the CPT code that represents the procedure they are training you to use. Codes 97124 and 97140 should not be used to bill for activities within the same session. Most of us could not distinguish when our therapist transitioned between the techniques used in 97124 to the techniques used in 97140 and vice versa. 97001 and 97002 are for physical therapy evaluation; these codes are for physical therapists and should not be used by massage therapists. Their use implies that the user is a physical therapist.