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).
