Permitted CPT Codes for Physical Therapy
Physical Therapists (PTs) spend countless hours working with clients to rehabilitate and strengthen them after injury. It’s really important that they are paid for their hard work, expertise and time spent, also helping to stay in business and continue providing care. Receiving insurance reimbursements for delivered services is a challenging job due to the level of specificity required in physical therapy billing. It’s important for physical therapists to have a strong understanding of how to bill both private insurance and Medicare for their services, to receive payment for their services. As most private insurances follow CMS billing guidelines (part B), we shared list of non-permitted and permitted CPT codes for applicable for Medicare.
Non-Permitted CPT Codes for Physical Therapy
In the same 15-minute (or other) time period, a physical therapist cannot bill any of the following pairs of CPT codes for outpatient therapy services provided to the same, or to different patients. Examples include:
- Any two CPT codes for ‘therapeutic procedures’ requiring direct one-on-one patient contact (CPT codes 97110-97542);
- Any two CPT codes for modalities requiring ‘constant attendance’ and direct one-on-one patient contact (CPT codes 97032 – 97039);
- Any two CPT codes requiring either constant attendance or direct one-on-one patient contact – as described in (a) and (b) above — (CPT codes 97032- 97542). For example: any CPT code for a therapeutic procedure (e.g., 97116-gait training) with any attended modality CPT code (e.g., 97035-ultrasound);
- Any CPT code for therapeutic procedures requiring direct one-on-one patient contact (CPT codes 97110 – 97542) with the group therapy CPT code (97150) requiring constant attendance. For example: group therapy (97150) with neuromuscular re-education (97112);
- Any CPT code for modalities requiring constant attendance (CPT codes 97032 – 97039) with the group therapy CPT code (97150). For example: group therapy (97150) with ultrasound (97035);
- Any untimed evaluation or re-evaluation code (CPT codes 97001-97004) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032 – 97039), therapeutic procedures (CPT codes 97110-97542) and group therapy (CPT code 97150)
Permitted CPT Codes for Physical Therapy
In the same 15-minute time period, one therapist may bill for more than one therapy service occurring in the same 15-minute time period where ‘supervised modalities’ are defined by CPT as untimed and unattended — not requiring the presence of the therapist (CPT codes 97010 – 97028). One or more supervised modalities may be billed in the same 15-minute time period with any other CPT code, timed or untimed, requiring constant attendance or direct one-on-one patient contact. However, any actual time the therapist uses to attend one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist.
Billing Requirements prior Submitting Claims to Medicare
CMS mentions list of billing requirements prior submitting claims to Medicare for part B therapy services:
- Physical and Occupational Therapists (PTs and OTs) and their therapy assistants – physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) meet Medicare personnel qualifications.
- All therapy provided consists of skilled and medically necessary services and is appropriate to each patient’s plan of care.
- Therapists can enroll in Medicare as providers of PT or OT services, but therapy assistants cannot. The services of the therapy assistant are billed through the enrolled therapist, or other therapy provider.
- The therapist reports the time the therapy assistant provides care, whether it is one-on-one care or delivered via the untimed codes, such as supervised modalities or group therapy.
- All Medicare rules are met with respect to supervision requirements for therapy assistants in their respective settings. For example:
- Direct (‘in the office suite’) supervision in private practice PT or OT therapy settings and
- General supervision in the following settings: Outpatient Prospective Payment System, Skilled Nursing Facility, Comprehensive Outpatient Rehabilitation Facility, Rehab Agency and the Home Health Agency.
- Each therapist’s supervision of therapy assistant(s) is in compliance with all State laws and regulations and with local medical review policies.
Above shared list of non-permitted and permitted CPT codes for physical therapy is applicable for Medicare. You can refer to payer specific billing and reimbursement guidelines for more accurate physical therapy billing. As discussed earlier, you need an expert physical therapy billing partner to handle physical therapy billing challenges. Legion Health Care Solutions is a leading medical billing company providing complete billing and coding services. Our custom billing services and pricing plans could exactly suit your physical therapy billing requirements. To know more about our physical therapy billing services, contact us at 727-475-1834 or email us at email@example.com
Reference: Part B Billing Scenarios for PTs and OTs
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