Evaluating Physical Therapy Billing

Therapy services have unique billing guidelines.  To prepare for reviewing the therapy bills obtain a copy of your physician’s prescription for service.  When attending therapy keep a daily log of your attendance and the services provided.  These two documents will allow you to evaluate your therapy bills.

The most common errors that we find when reviewing physical therapy bills are:

• Services billed, but not provided
• Duplicate billing for services
• Services billed that are not separate services, but rather a part of the parent code (unbundling).
• Billing for individual service when group service was provided
• Services provided that were not ordered
• Time based services not documented as to the amount of time the therapist work with the patient.

Physical therapy evaluations (97001) and re-evaluations (97002) include assessment and documentation of the patient’s history, level of function, systems review, specific tests and measures, diagnosis, and prognosis.

A lot of physical therapy treatment is described as a modality.  A modality is any physical agent applied to produce therapeutic changes to biologic tissue.  These include, but are not limited to thermal, acoustic, light, mechanical, or electric energy.”

Some modalities, such as traction, unattended electrical stimulation, and whirlpool treatment, are “supervised” by the therapy provider, but don’t require one-on-one contact during the treatment.  Supervision in this case would mean that the physical therapist is available within the treatment area to intervene one-to-one if necessary.  As defined by CPT, supervised modalities are not timed services (CPT codes 97010–97028).

Other modalities, including manual electrical stimulation, ultrasound, and iontophoresis (using an electrical charge to deliver medication to inflamed tissue), are defined as “constant attendance” services that require one-on-one contact with the physical therapist or therapy provider. These codes (CPT codes 97032–97039) are timed and billable in 15-minute increments.

Therapeutic procedures (CPT codes 97110–97546) are another type of physical therapy service.  These services are also timed and require direct, one-on-one patient contact. Examples include therapeutic exercises and activities, neuromuscular re-education, aquatic therapy, gait training, and manual therapy. Therapeutic exercises and activities typically involve the use of gym-style equipment, stairs, or therabands (TheraBand™ are latex exercise bands utilized for resistive exercise).

Active wound care management (CPT codes 97597–97606)—Wound care services promote healing by removing devitalized and necrotic tissue from the patient’s body. The provider has direct contact with the patient, and codes are determined by the type of debridement and wound surface size.

Tests and measurements (CPT codes 97750–97755)—Although tests and measurements are a component of evaluation and re-evaluation, employers or insurance carriers may request specialized testing or assessment, which are reported using these codes.

Orthotic and prosthetic management (CPT codes 97760–97762)—therapists may provide specialized training in the use of orthotics and prosthetics, which is reported as a unique service.

Physical Therapy billing codes are either timed or untimed codes for billing purposes. Untimed codes are reported as one unit per day regardless of how many body parts are treated with the modality.  It does not matter if you spend one hour or two hours with this type of treatment.

The following are untimed codes:

• 97001 – Physical Therapy Evaluation
• 97002 – Physical Therapy Re-Evaluation
• 97010 – Hot or cold packs
• 97012 – Traction, Mechanical
• 97014 (G0283) – Electrical Stimulation
• 97024 – Diathermy
• 97028 – Ultraviolet

Timed codes are reported using the Medicare 8 Minute Rule.  When billing more than one timed CPT code on a calendar day, the total number of units that provider may bill may not exceed the total treatment time the therapist and the patient spent one-to-one time together.

Timed codes are billed using Medicare’s 8 Minute Rule to determine how many units a day a particular CPT code can be charged.  The following codes are timed codes:

• 97032 – Electrical Stimulation (Manual)
• 97033 – Iontophoresis
• 97035 – Ultrasound
• 97039 – Unlisted
• 97110 – Therapeutic Exercise
• 97112 – Neuromuscular Reeducation
• 97116 – Gait Training
• 97124 – Massage
• 97139 – Unlisted
• 97140- Manual Therapy
• 97530 – Therapeutic Activity

Below is the 8 Minute Rule chart to help you determine the total number of minutes that service was provided and the total number of units you can bill during one therapy session:

Units	Number of Minutes
0 Units	< 8 Minutes
1 Unit	>= 8 Minutes and <= 22 minutes
2 Units	>= 23 Minutes and <= 37 minutes
3 Units	>= 38 Minutes and <= 52 minutes
4 Units	>= 53 Minutes and <= 67 minutes
5 Units	>= 68 Minutes and <= 82 minutes
6 Units	>= 83 Minutes and <= 97 minutes
7 Units	>= 98 Minutes and <= 112 minutes
8 Units	>= 113 Minutes and <= 127 minutes

First, add up the total treatment time for timed codes (do not include the time spent treating for untimed codes). You then take the total treatment time for timed codes and look up the maximum number of units you can bill for on the 8 Minute Rule Chart.

If a service represented by a 15 minute timed code is performed in a single day for at least 15 minutes that service shall be billed for one unit. If the service is performed in a single day for at least 30 minutes, the service shall be billed for at least two units, etc. You cannot count all minutes of treatment in a day toward the units for one code if other services were performed for more than 15 minutes.

When more than one service represented by 15 minute timed codes is performed in a single day, the total number of minutes of service determines the number of timed units billed.

If any 15 minute timed service is performed for 7 minutes or less on the same day as another 15 minute timed service that was also performed for 7 minutes or less and the total time of the two services is 8 minutes or greater, then you bill one unit for the service performed for the most minutes. This is because the total time is greater than the minimum time for one unit. The same logic applies when three or more different services are provided for 7 minutes or less. The expectation is that a provider’s direct patient contact time for each unit will average 15 minutes in length. If a provider has a consistent practice of billing less than 15 minutes for a unit, this should be highlighted for review.

If more than one 15 minute timed code is billed during a single calendar day, then the total number of timed units can be billed up to the maximum number of units allowed based on the total treatment time for that day.  The total number of timed minutes must be documented!

There is one exception to the timed codes for codes 97545 and 97546. These specialized codes are used for rehabilitating a worker to return to the job and the expectation is that the entire time period specified for 97545 and 97546 would be the treatment period. The code 97545 is for the time period included in the first 2 hours, the code 97546 includes the time period for each additional hour (after the first 2 hours).