physical therapy office visit cpt code

A Comprehensive Guide to Mastering CPT Physical Therapy Codes

Are you looking to become an expert in creating CPT physical therapy codes? If so, this blog post is for you! This comprehensive guide introduces the basics of CPT physical therapy codes, common codes used in practice, how to correctly create and use them, and the importance of coding compliance. 

We will also provide tips for accurate code creation and update readers on any changes to coding guidelines. By the end of this post, you will have a better understanding of how CPT physical therapy codes are used in physical therapy and what strategies need to be implemented in order to ensure coding accuracy and compliance.

Accurate coding is critical in physical therapy as it ensures that patients receive the appropriate care and that providers receive proper reimbursement for their services. Our aim is to help physical therapists to better grasp coding principles, nuances, and updates. 

In this way, they can avoid coding errors that can lead to denied claims, audits, or even legal consequences. Our guide will help physical therapists navigate the complex landscape of CPT physical therapy codes and confidently submit claims for the services they provide.

Understanding the Basics of CPT Physical Therapy Codes.

CPT (Current Procedural Terminology) codes are alphanumeric codes that represent a wide range of services, procedures and products related to healthcare. They have been developed by the American Medical Association (AMA) as a set of standards to ensure that medical billing is done uniformly and accurately across all providers. 

CPT physical therapy codes are used in physical therapy to identify specific treatments and services provided, enabling accurate insurance reimbursement for those services.

CPT physical therapy codes are also helpful in tracking patient progress and assessing treatment effectiveness. By using specific codes for each treatment, physical therapists can easily reference a patient’s previous treatments and determine the most effective next steps. 

In addition, the use of CPT physical therapy codes ensures that insurance companies are only billed for the treatments provided and not for unnecessary or incorrect procedures. Overall, CPT physical therapy codes are an essential tool for physical therapists to ensure accurate billing, track progress, and provide the best possible care to their patients.

Types of CPT Physical Therapy Codes

There are several types of CPT physical therapy codes, each designed to meet the needs of different types of patients or practitioners. Commonly used categories include evaluation/management (E/M) codes, therapeutic procedure codes, orthotic & prosthetic management codes, modalities code, and other commonly used codes such as aquatic therapy or manual therapy techniques.

Evaluation/management (E/M) codes are used for initial assessments, re-evaluations, and ongoing management of a patient’s condition. These codes typically include history-taking, physical examination, and developing a treatment plan. Therapeutic procedure codes are used for a wide range of treatments, including manual therapy, therapeutic exercises, and functional training. 

Orthotic & prosthetic management codes are used for the fitting and management of assistive devices such as braces or artificial limbs. Modalities codes are used for the application of various physical agents, such as heat or electric stimulation. 

By using these codes, physical therapists can accurately document the services provided and ensure proper reimbursement for their services.

The Benefits of Using CPT Physical Therapy Codes

By properly coding physical therapy services with the correct CPT physical therapy codes, providers can ensure that they receive appropriate payment from insurance companies for the service rendered in a timely manner. Additionally, using standardized coding helps prevent billing errors while providing an efficient way to track patient care records and outcomes over time

Using accurate and detailed coding also enables physical therapists to better communicate with other healthcare providers and insurance companies, ensuring a higher quality of care for their patients. 

Furthermore, consistent coding practices can help identify areas where therapy may be underutilized or overutilized, allowing providers to make necessary adjustments in their treatment plans. 

With proper coding, physical therapy providers can optimize their reimbursement and improve patient outcomes through effective communication and data analysis.

Explanation of CPT physical therapy codes in physical therapy

In order for insurers to correctly reimburse providers for their work it is essential that they be supplied with accurate information regarding what services were performed on a particular patient at any given appointment along with any associated diagnoses or conditions being treated during this same visit. 

In addition to this information it is also necessary for a proper diagnosis related group (DRG) code which will further aid in providing an accurate picture about why these particular treatment strategies were chosen in order for reimbursement purposes. 

This is where using standardized coding systems like CPT comes into play as it allows both providers and payers alike know exactly what treatments were delivered without confusion or ambiguity between parties involved

For example, if a physician uses a specific CPT physical therapy code to indicate that they performed a certain surgical procedure on a patient, the payer can easily process the claim and reimburse the provider accordingly. Without a standardized coding system, the process would be much more difficult and time-consuming. 

Additionally, using CPT physical therapy codes can aid in research efforts by allowing for easier categorization and analysis of medical data. Overall, the use of standardized coding systems like CPT is essential to the efficient and effective operation of the healthcare industry.

How do you select the right code?

Selecting the correct code can often be tricky even when you understand how coding works; therefore there are certain steps one should take prior to submitting claims: 

First assess your patient thoroughly so you have a clear idea what diagnosis they have been given by their physician; second review ICD-10-CM diagnostic guidelines related to those diagnoses; third determine if the treatment provided falls within standard guidelines specified by CMS; fourth apply relevant modifiers if applicable; fifth check against payer policies specific covered benefits ; sixth verify coverage policy requirements before choosing final diagnosis related group assignment number.

The goal when selecting any type of code should always be accuracy as incorrect ones may result in denials or even retroactive adjustment requests leading potential financial losses.

To achieve accuracy, it is important to ensure that the code selected matches the documentation, which can sometimes be a challenge due to the complexity and ever-changing nature of medical terminology. Additionally, proper training for the coders is crucial to ensure consistent and correct coding practices. 

This includes staying up to date with the latest coding guidelines and regulations, as well as understanding the nuances of different payer policies. By prioritizing accuracy and investing in the necessary resources, healthcare organizations can avoid costly coding errors and maximize revenue opportunities.

Common Physical Therapy CPT Codes

Evaluation and management (E/M) CPT physical therapy codes are used to report medical services for physical therapy evaluation. These codes provide information about the patient’s condition, service provided, and time spent with the patient. 

Examples of E/M CPT physical therapy codes that are commonly used in physical therapy include: 99202 (new patient office visit), 99212 (established patient office visit), 97161 (physical therapy re-evaluation), 97124 (massage) and 97140 (manual therapy-techniques).

These E/M CPT physical therapy codes are essential in determining the reimbursement and billing process for physical therapy services. Each code is unique and reflects the type of service provided during the patient visit. The 99202 and 99212 codes represent office visits, while the 97161 code represents physical therapy re-evaluation visits. 

Additionally, the 97124 code is used for massage therapy services, while the 97140 code is used for manual therapy techniques. Proper coding and billing of these services help ensure appropriate payment for services provided and accurate medical reporting.

Therapeutic procedure codes

Therapeutic procedure codes are used to report medical services for therapeutic exercises, manual therapy techniques, and other therapeutic interventions performed by a physical therapist. 

Examples of these CPT physical therapy codes typically found in physical therapy settings include: 97110 (therapeutic exercise), 97112 (neuromuscular re-education), 97116 (gait training) and 97140(manual therapy techniques).

These CPT physical therapy codes are used not only for billing purposes, but also to track the progress and effectiveness of the physical therapy interventions. Each code has specific requirements and documentation needed to justify its use. 

For example, therapeutic exercise may involve strengthening or stretching exercises tailored to the patient’s individual needs and goals. Neuromuscular re-education may involve teaching the patient how to properly activate and use specific muscles. 

Gait training may involve relearning how to walk or improving balance and coordination while walking. Manual therapy techniques may involve hands-on techniques such as massage or joint mobilization to improve range of motion and decrease pain.

Orthotic and prosthetic management codes

Orthotic and prosthetic management codes refer to services related to the fitting, fabrication or modification of orthoses or prostheses used as part of a treatment plan prescribed by a physician or qualified health care provider. 

Commonly reported CPT orthotics/prosthetics code include: L3650(orthosis – lower leg-ankle foot); L3660(orthosis – ankle foot); A4576(orthosis – knee ankle foot); A4580(orthosis – upper extremity).

These codes are often used in medical billing and coding for patients who require orthotics or prosthetics to assist with mobility issues. Orthotics are devices worn on the body to correct or support musculoskeletal conditions while prosthetics are used to replace missing limbs. 

Orthotics and prosthetics can greatly improve a patient’s quality of life, enabling them to perform daily tasks and increasing their independence. Proper coding and billing for these devices is essential in ensuring that patients receive the appropriate coverage for their necessary medical equipment.

Modalities Codes

Modality is an intervention technique intended to affect tissue through thermal, electrical current, electromagnetic radiation or mechanical vibration agents such as ultrasound or iontophoresis devices being applied on patients for specific physiological effects such as pain relief or tissue healing purposes. 

Commonly reported modality CPT physical therapy codes include 97032(electrical stimulation); 97035(ultrasound diathermy); 97039(unlisted modality).

These codes are used by healthcare professionals and billing personnel to accurately record the type of treatment used during a patient’s therapy session. However, it is important to note that the use of CPT physical therapy codes can be complex and requires a thorough understanding of the coding system. 

Improper coding can result in denial of payment and other billing errors, which can have a negative impact on the revenue cycle of healthcare facilities. It is therefore recommended that healthcare providers consult with coding experts to ensure accurate coding and billing practices.

Other Commonly Used Codes

Other commonly used CPT physical therapy codes includes; G0283–Aquatic Therapy; HCPCS G0463–Manipulation Under Anesthesia; 96125–Neurodevelopmental Training; 97530–Therapuetic Activities; 98953—Telehealth Services etc…

G0283 is a commonly utilized code for aquatic therapy, which involves performing exercise and movements in water. This therapy can be especially beneficial for patients experiencing joint pain, muscle weakness, or difficulty with weight-bearing exercises. 

HCPCS G0463 is used for manipulation under anesthesia, a technique that involves manipulating joints while a patient is under anesthesia following surgery. Neurodevelopmental training, represented by CPT code 96125, is used to improve the cognitive, behavioral, and motor skills of patients with neurodevelopmental disorders. 

Finally, 98953 refers to telehealth services provided by physical therapists via video conferencing, which has become increasingly important in the current digital age that necessitates remote communication.

Mastering the Process of Coding for Physical Therapy Services.

Creating CPT physical therapy codes is a process that requires understanding of the coding language and guidelines so that your claims are successful and properly reimbursed. The general steps in creating a CPT code for physical therapy services include:

1. Identify the appropriate service being provided, including any pertinent details such as site or type of therapy.

2. Determine if the service is billable based on payer policies and other regulations, like Medicare guidelines.

3. Locate the correct code for the service in either an online database or reference manual, such as the CPT Codebook from the American Medical Association (AMA).

4. Complete necessary documentation to support billing for the identified ICD-10 diagnosis code(s), including any additional information needed to support medical necessity of care provided such as physician orders or preauthorization requests from third party payers if applicable . Also obtain authorization number from insurance company when required prior to providing services

5. Enter information into billing system about patient demographics, diagnosis codes and specific procedure codes associated with treatment performed along with modifiers when applicable .

6. Obtain signature(s) confirming patient’s consent for services rendered and submit claim electronically through practice management software, clearinghouse or directly to insurer depending on payment cycle policy established by organization

7 Transmit claim electronically after verifying all information is accurate and complete; confirm receipt of claim submission via acknowledgement report received back from payer

Tips for Accurate CPT Physical Therapy Code Creation.

Accurate coding is essential in order maximize reimbursement while minimizing risk of audit penalties or non-payment due to incorrect coding practices:

• Always pair each patient’s evaluation/assessment service with a corresponding therapeutic procedure code when possible (each must be separately reported); this will help ensure all aspects of care are captured correctly and not overlooked when determining reimbursement rates associated with treatment plan prescribed 

• Utilize modifiers appropriately since they provide additional detail about what type of service was performed (i.e., bilateral vs unilateral extremity treatments) which can impact reimbursement rate; use only ones relevant to treatment services rendered – avoid misuse since this could lead to denial/delay of payment despite submitting accurate codes

• Crosswalk ICD-9 diagnoses codes over to ICD-10 where applicable; also familiarize yourself with new “Z” 4th digit designations included under some family categories which further enhances specificity when documenting condition treated 

• Double check all procedures listed against current fee schedule prior submitting claim; verify you have using most updated version available whenever possible (these may change throughout year )

• Include written justification along line itemized charges if requested by payer during review process as part of their requirement validate why medical intervention deemed medically necessary 

• Stay informed regarding changes regulatory standards/guidelines by subscribing newsletters newsletters related topics related topics certification programs offered through AMA Subsection 3.3 Common Mistakes To Avoid When Creating CPT Physical Therapy Codes: 

• Forgetting utilize modifier 31 when reporting initial visit /evaluation;;this affects amount paid since separate value assigned based complexity level care provided at point time 

• Not pairing assessment procedure code together properly results both billed separately therefore no increased rate between two items which may limit potential revenue generated 

• Billing higher levels than clinically indicated seen commonly done incorrectly documented history physical exams use 99213 instead 99212 even though lower level appropriate given complexity issue presented; 

Also watch out overuse unlisted category quickly flagged auditors seek clarity behind reason given not covered rather than assuming one fits better due inaccurate documentation Subsection 3.4:

Importance Of Accurate Coding: While knowledge base required understand create accurate physical therapy coding important remember end goal always compliant set forth providers remain profitable successful long run Having solid foundation building blocks place helps ensure compliance payer regulations well reimbursement due success claims submitted utilizing correct codes

Coding for physical therapy services can be a tricky process, but it is important to stay up-to-date on the changes in CPT physical therapy codes and coding guidelines. With the right knowledge and preparation, you can create accurate CPT physical therapy codes that will maximize reimbursement while avoiding mistakes that could lead to audit penalties or non-payment of claims.

The Importance of Coding Compliance in Physical Therapy.

Coding compliance in physical therapy refers to the practice of correctly coding services provided by a physical therapist and adhering to the guidelines set forth by the American Medical Association (AMA). 

The purpose of coding compliance is to ensure that providers are accurately billing for services rendered, protecting both patients and practitioners from potential financial penalties or incorrect payments.

It is important for healthcare providers to stay up-to-date with the latest coding guidelines and regulations to avoid any potential legal and financial repercussions. A coding compliance program should include regular audits and education for staff to ensure they are following correct coding and documentation practices. 

It also helps to minimize the risk of any potential fraud, waste, or abuse by maintaining accurate records and practices. Ultimately, coding compliance is an essential part of maintaining ethical and legal standards in healthcare billing and ensuring fair compensation for services provided.

Benefits of Coding Compliance in Physical Therapy.

Maintaining coding compliance within physical therapy has numerous benefits, including:

• Increased accuracy – Accurate codes help reduce errors that can lead to costly claims denials or inaccurate payments.

• Increased efficiency – Correctly coding patient information allows providers to be more efficient when submitting bills, ultimately streamlining administrative tasks and improving turnaround times.

• Improved communication – Properly coded records provide additional clarity when communicating with other healthcare professionals, ensuring everyone has accurate information about a patient’s treatment plan and progress.

• Reduced risk of fraud – By utilizing accurate codes, providers are better able to identify potentially fraudulent activities before they occur, thus minimizing their liability and protecting against financial penalties associated with improper billing practices.

Strategies for Ensuring Coding Compliance in Physical Therapy.

To ensure proper coding compliance within physical therapy practices, it is important that all staff members understand how codes work and how they should be used properly during each visit with a patient. 

Staff should also be trained on procedural documentation guidelines as well as any applicable reimbursement policies related to code usage and reporting requirements mandated by insurers or government regulations such as Medicare/Medicaid rules for Medicaid/Commercial insurance payers respectively. 

Additionally, providers should utilize up-to-date resources such as the Centers for Medicare & Medicaid Services (CMS) website or other online resources on topics like ICD-10 conversion changes whenever possible to stay informed about changes in coding standards and protocols .

Documentation Requirements

Having clear documentation procedures is crucial for achieving code accuracy across all visits with patients–from initial exams through any follow up care needed over time–as this helps protect against errors due to incomplete notes or missing information which could result in denied claims down the line due to lack of proof of service rendered. 

Providers must document every step taken during a patient’s treatment plan so they can easily reference notes if necessary while creating individualized codes each visit; failure to do so could result in incorrect use of codes when submitting claims which may then end up being rejected due insurers unsure if these were valid charges incurred during that particular visit period.

Updates and Changes to CPT Codes for Physical Therapy

Annual updates to the Current Procedural Terminology (CPT) codes for physical therapy are necessary in order to keep up with changing technology, better reflect clinical practice and stay compliant with health insurance requirements. 

These updates are released on an annual basis by the American Medical Association (AMA). To ensure accuracy, physical therapists should stay abreast of any revisions or additions that are made to CPT physical therapy codes each year.

Staying up to date with these codes is crucial for billing correctly and receiving appropriate reimbursement for services rendered. Additionally, understanding the codes can facilitate communication with other healthcare professionals in order to accurately document patient care. 

It is important for physical therapists to take the time to review and understand any changes to CPT physical therapy codes in order to maintain compliance with current regulations and avoid potential audit penalties.

Changes to coding guidelines

In addition to yearly updates, there can also be changes made at any time throughout the year regarding coding guidelines for physical therapy services. 

For example, a new code might be added if a specific type of treatment becomes more popular or is more frequently offered in physical therapy practices. 

Or, a code may be revised if there’s been a change in how it’s typically utilized by physical therapists. It’s important that all physical therapists remain informed about these types of coding changes as they could have a direct impact on their practices and revenue streams.

In addition, physical therapists should also be aware of billing and reimbursement policies and regulations to ensure that their claims are being paid correctly and in a timely manner. 

Staying up-to-date with the latest coding and billing practices can help physical therapists avoid claim denials or delays, which can create additional workload and financial stresses. 

Therefore, attending continuing education courses and seeking guidance from billing and coding experts can prove to be beneficial for physical therapists in managing their practices effectively.

Impact on physical therapy practices

Any changes to CPT physical therapy codes can have significant implications for both short-term and long-term reimbursements from health insurers and other entities that cover healthcare costs. 

Physical therapists must pay attention when changes occur so that they can adjust their billing procedures accordingly so as not to miss out on potential reimbursement opportunities or receive less than what is due due them for services rendered. 

Additionally, staying updated with coding guidelines ensures accurate recordkeeping which is extremely important from legal perspectives as well as audit trails and quality assurance measures required by insurers.

Having an organized and accurate medical coding system helps in preventing coding errors and inconsistencies, which can lead to denied claims, underpayment, or overpayment. It also helps in identifying potential compliance issues and risks, and in mitigating them before they escalate into bigger problems. 

As the healthcare landscape continues to evolve, it is vital for medical coders to keep themselves informed of the latest changes in medical terminology, diagnosis codes, and reimbursement policies. 

Doing so not only enhances their competency and credibility as professionals, but also contributes to better patient outcomes and cost-effective healthcare delivery.

In conclusion, CPT physical therapy codes are an essential tool for physical therapists to accurately document and bill for services. By understanding the basics of CPT physical therapy codes, mastering the process of creating them, and being aware of coding compliance requirements, physical therapists can ensure they are compliant with all relevant regulations while maximizing their reimbursements. 

It is important to stay up to date on any changes or updates to CPT physical therapy codes in order to maintain accuracy and compliance. Ultimately, having a comprehensive knowledge of CPT physical therapy codes is essential for any successful physical therapy practice.

It’s important for physical therapists to take advantage of this resource so that they can remain successful in their business operations. We invite you to learn more about how you can master your CPT coding skills by visiting our website today!

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December 24, 2023

A comprehensive guide to physical therapy cpt codes.

Navigating the intricate world of physical therapy CPT codes can feel like traversing a medical labyrinth. Worry not, intrepid therapist! 

This guide equips you with the knowledge and tools to conquer codes with confidence, ensuring accurate billing and seamless reimbursement.

What are CPT Codes?

Current Procedural Terminology (CPT) codes are a standardized language used by healthcare professionals to document the services and procedures they provide. Think of them as unique identification tags for every medical intervention, similar to barcodes in a supermarket. 

In the world of physical therapy, CPT codes represent the specific treatments, evaluations, and modalities patients receive during sessions.

How Do CPT Codes Work?

Each CPT code consists of five digits and describes a specific service. For example, 97110 refers to therapeutic exercise, while 97035 represents ultrasound therapy. 

This information is then submitted to the patient's insurance company along with a claim for reimbursement.

Physical Therapy CPT Codes and Insurance

The magic happens when a CPT code meets the patient's insurance plan. Physical therapy CPT codes act as the bridge between the services a patient receives and the financial compensation for the therapist. Insurance companies use these codes to determine how much they will reimburse for each service. Here's how the process unfolds :

• The therapist documents the physical therapy CPT codes for the services provided during a session. 
• These codes are submitted to the patient's insurance company along with a claim for reimbursement. 
• The insurance company reviews the codes and applies their specific fee schedule to determine the reimbursement amount. 
• The therapist receives a portion of the reimbursement, while the patient may be responsible for a co-pay or deductible depending on the patient's plan.

So, Who Submits CPT Code Claims to Insurance Companies?

While you might encounter physical therapists tackling claims themselves in smaller practices, larger clinics often have dedicated billing specialists or even outsource to third-party companies. Regardless of who submits the claim, the process generally involves the therapist documenting services with CPT codes, preparing forms, submitting electronically, receiving insurance responses, and managing patient billing for any remaining amounts. 

Opting for practice management software like PtEverywhere takes claim submissions to the next level. This software streamlines the process with features like integrated CPT code databases, automated claim generation, and error checking, all while reducing paperwork and boosting efficiency. 

PtEverywhere even assists with insurance verification and manages denials, saving you time and frustration. Ultimately, it puts you in control and empowers you to focus on what matters most - providing top-notch patient care.

Understanding the Categories of CPT Codes

Imagine CPT codes as a secret code used by physical therapists to communicate with insurance companies. Cracking this code is essential for getting reimbursed for your services. This guide will unveil the different types of CPT codes and how they apply to physical therapy.

Category I: The Workhorses of Billing

These are the most common CPT codes, like trusty workhorses. They're five-digit numeric codes (think 97110 for therapeutic exercise) that represent widely used procedures in physical therapy. Insurance companies and healthcare organizations recognize these codes, ensuring you get paid for established treatments. Category I codes are organized into sections like surgery or medicine, making it easier to find the right code for your service. New codes are added every year to keep pace with evolving practices.

Category II: Tracking How We Do

These optional codes (think 47100F) are different. They're alphanumeric (letters and numbers) and focus on tracking how well we deliver care. They don't affect billing, but they help us gather data on patient progress and treatment effectiveness. Imagine them as tools to improve the quality of physical therapy services. These codes have subcategories like "patient history" or "interventions performed," allowing therapists to track specific details about each treatment session. New Category II codes are released frequently to adapt to changing measurement needs.

Category III: Codes for the Future

These temporary codes (think 97799T) are like placeholders for brand new physical therapy practices or technologies. They're five digits ending in "T" and track cutting-edge treatments that are still under development or evaluation. These codes help researchers and therapists understand how well these new approaches work. If a treatment with a Category III code becomes widely used, gets FDA approval, or shows proven effectiveness, it might graduate to a permanent Category I code. The list of Category III codes is updated twice a year to reflect the latest advancements in physical therapy.

15 Most Common Physical Therapy CPT Codes

Here are the 15 most common category I, PT CPT codes, along with their descriptions and estimated ranges of Medicare reimbursement:

Please note: These are estimated reimbursement ranges based on Medicare data. Actual reimbursement amounts may vary depending on your location, payer policies, and individual billing practices. It's always advisable to check with your payer for specific coding and reimbursement guidelines. For a quick reference, you can use the Medicare Payment Finder tool to view estimated rates for various physical therapy CPT codes.

Why are ICD-10 and CPT Codes Different?

Forget code conundrums, PTs! Demystifying ICD-10 and CPT codes unlocks the doors to smooth operations and optimal patient care. Think of them as partners in documentation and reimbursement, each playing a unique role: 

ICD-10: These five-character detectives crack the case of "what's wrong," pinpointing diagnoses like M54.5 for low back pain. They tell the story behind the symptoms, justifying treatment and paving the way for insurance coverage. 

CPT codes: These five-digit action heroes reveal the "what we did," detailing interventions like 97110 for therapeutic exercise. They showcase the value you deliver, ensuring you receive your well-deserved reimbursement.

Here’s an example to show the relationship between these codes better: Jessica, the violinist, silenced by pain, finds relief in your PT expertise. ICD-10 code M77.1 reveals her tennis elbow, while physical therapy CPT codes 97140, 97110, and 97010 showcase your manual therapy, exercises, and hot packs treatment. Insurance hears this code combination, reimburses you, and Jessica's violin sings again, proving the power of code harmony in PT care.

Enter the Modifiers: Why are they Important?

While ICD-10 and CPT codes for PT take center stage in physical therapy billing, modifiers play a crucial supporting role . Think of them as the code whisperers, adding nuances and clarifying details to ensure accurate reimbursement and compliance with insurance regulations.

Key Modifiers in PT:

• -59 Distinct Procedural Service: Indicates that two or more services performed during the same session were distinct and separate, justifying separate reimbursement. 
• -52 Reduced Services: Signals that a service was less extensive than typically reported by the CPT code, often due to patient factors or time constraints. 
• -25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: Used when a significant evaluation and management service is provided on the same day as a procedure or other service, warranting additional reimbursement. 
• GX, GN, GO, GP : Identify the provider who performed the service (therapy assistant, occupational therapist, speech-language pathologist, or physician), essential for proper reimbursement allocation.

Example in Action:

Remember Ms. Jones, the golfer with chronic back pain? Imagine you provide manual therapy (97140) and therapeutic exercises (97110) in the same session, but for distinct body regions. To ensure proper reimbursement, you'd append modifier -59 to one of the codes, signaling their separate nature.

By embracing modifiers, you add a layer of precision to your billing narrative, ensuring clarity for insurance companies and maximizing reimbursement for your valuable services. They are the subtle whispers that make a significant difference in the financial symphony of physical therapy practice.

Check out this blog for a detailed guide on how to use modifiers with CPT codes physical therapy clinics often have to deal with!

Let’s Not Forget About CCI Edits and Their Role in CPT Coding!

In the realm of physical therapy billing, encountering the CCI (Correct Coding Initiative) is inevitable. It's a set of guidelines designed by CMS (Centers for Medicare & Medicaid Services) to ensure accurate coding and prevent improper payment for specific code combinations. Understanding CCI is crucial to avoid claim denials and reimbursement challenges.

How CCI Works:

The intricacies of physical therapy billing are further governed by the Correct Coding Initiative (CCI), a set of guidelines designed to prevent improper payment for certain code combinations. Think of it as a sophisticated filter, scrutinizing pairs of CPT codes and assigning them "traffic lights" to ensure accurate reimbursement:

• Green Light (Modifier 9) : These pairings flow freely, representing services distinct enough to warrant separate payment (e.g., manual therapy on separate body regions).
• Yellow Light (Modifier 1): Caution is advised. While billing both codes is permissible, justification and a specific modifier might be required to explain their individual medical necessity (e.g., hot packs followed by targeted neuromuscular re-education). 
• Red Light (Modifier 0): These combinations are deemed redundant or impossible to perform simultaneously (e.g., billing separate codes for manual therapy on the same region).

CCI Example in Action:

Sarah arrives at Dr. Lee's PT clinic with a persistent ache in her right shoulder, hampering her daily activities. Dr. Lee devises a personalized treatment plan featuring a combination of manual therapy (CPT 97140) to loosen tight muscles and neuromuscular re-education (CPT 97112) to retrain movement patterns. While both interventions are crucial for Sarah's recovery, they trigger a yellow flag in Dr. Lee's mind: the CCI guidelines .

Knowing that certain code combinations require careful consideration, Dr. Lee consults the latest CCI edits. He discovers that pairing 97140 and 97112 falls under Modifier Indicator 1, meaning they're "allowed with a modifier." This yellow flag serves as a cautionary beacon, prompting justification for separate billing.

Instead of panicking, Dr. Lee embraces the nuance. He meticulously documents the session, highlighting the distinct goals and techniques employed for each intervention. For the manual therapy, he details the specific muscles targeted and the range of motion exercises performed. For the neuromuscular re-education, he outlines the targeted exercises and their role in retraining proper movement patterns.

By understanding and adhering to CCI guidelines, Dr. Lee ensures accurate and justified billing for his services. He navigates the potential roadblock of CCI edits with clear documentation and the right modifier, allowing him to focus on what truly matters – Sarah's recovery and the financial sustainability of his practice. This case study exemplifies how mastering CCI complexities can pave the way for smooth billing and ensure optimal financial health for physical therapists who strive to deliver outstanding patient care.

Evaluation and Re-evaluation: Cornerstones of PT Billing Accuracy

In the intricate world of physical therapy billing, evaluation and re-evaluation codes stand as critical building blocks, ensuring both quality care and financial sustainability. Let's break down their distinct roles:

The Initial Evaluation (CPT 97161)

This code lays the groundwork by establishing a comprehensive picture of the patient's condition. From detailed medical history and functional assessments to range of motion and movement analyses, every piece of information contributes to crafting the initial treatment plan. Think of it as the architectural blueprint, guiding the course of therapy with precision.

The Following Re-evaluation (CPT 97162)

As therapy progresses, re-evaluations act as vital checkpoints, ensuring the treatment plan remains relevant and effective. This physical therapy CPT code allows PTs to assess progress at regular intervals, comparing current findings to the initial baseline. Like a conductor fine-tuning an orchestra, the PT identifies areas of improvement and makes necessary adjustments to keep the therapy in sync with the patient's evolving needs.

Ensuring Accurate Billing for Evaluation and Re-evaluation

Accurate reimbursement hinges on understanding the code requirements. Remember, both evaluation and re-evaluation are distinct services, even if billed on the same day. Clear documentation becomes crucial here, meticulously outlining the specific findings and rationale for each assessment to justify separate billing. 

In certain cases, modifier -59 can be a handy tool. When both evaluations share the stage on the same day, this modifier subtly signals to insurance companies that while performed concurrently, they serve distinct purposes and deserve individual recognition. 

Staying informed about CCI edits and payer-specific guidelines is also paramount. These act as the musical score, dictating the specific rules and nuances of each insurance plan. By regularly consulting these resources, you can avoid billing pitfalls and ensure smooth financial harmony.

Harnessing Technology for Seamless CPT Mastery

Navigating the intricate dance of PT CPT codes, modifiers, and billing guidelines can feel like a one-step forward, two-steps back waltz. But what if your steps were guided by a seasoned management system , ensuring every move leads to perfect rhythm and financial harmony?

Enter PtEverywhere, your all-in-one PT practice management software, ready to transform this complex operation into an efficient process.

• Built-in Expertise at Your Fingertips: Ditch the manual code lookups and potential errors. PtEverywhere comes equipped with a comprehensive PT CPT codes library, ensuring you always select the right codes, modifiers, and ICD-10 pairings for each service. No more missed notes or misplaced steps.
• Effortless Documentation: Say goodbye to tedious charting. Customizable templates, auto-populated fields, and intuitive interfaces make recording every detail a breeze. Streamline your workflow and ensure accurate billing, no sweat.
• Compliance in Real-Time: Stay ahead of claim denials and billing hurdles. PtEverywhere scans for potential CCI conflicts before you submit, gently guiding you to make adjustments and protecting your revenue from unexpected disruptions. No need to fear the complex rhythm of regulations.
• Navigating the Insurance Maze: Don't get lost in the labyrinth of payer-specific rules. PtEverywhere incorporates guidance on individual insurance requirements, ensuring your claims waltz their way to optimal reimbursement. Maximize your financial potential without losing a beat.
• Data-Driven Insights for Continuous Improvement: Uncover the hidden melodies of your practice data. PtEverywhere's robust reporting capabilities let you track coding trends, identify areas for improvement, and make informed decisions to enhance both clinical and financial outcomes. Optimize your every movement with the power of knowledge.

Bottom Line

In conclusion, mastering the intricacies of CPT codes for physical therapy doesn't have to be a solo waltz. Partnering with PT practice management software like PtEverywhere transforms the process from a cumbersome chore into a seamless, managed system.

PtEverywhere empowers you to code with confidence, optimize practice performance, and ultimately focus on what truly matters - delivering exceptional patient care and safeguarding your practice's financial well-being. 

So, are you ready to take your CPT coding and practice management skills to a whole new level? 

Embrace the power of PtEverywhere and discover the transformative melody of streamlined workflows, accurate billing, and thriving practice success.

Physical Therapists’ Guide to Billing

With our guide to billing, physical therapists and other rehab professionals can get best practices on coding, modifiers, and more.

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You became a physical therapist to help people; you didn’t do it for the money. But in order to stay in business long enough to actually make a difference in your patients’ lives, you absolutely must bill—and collect payment—for your services. (How else do you plan to keep the lights on?) For physical therapists, physical therapy billing is a fact of life, but that doesn’t mean the process should be overwhelming. And that’s true whether you’re a seasoned veteran or a fresh graduate. 

Read on to learn everything you need to know about billing guidelines in this physical therapists’ billing guide—well, a lot of it, anyway.

What are the codes?

The international classification of diseases (icd).

In order to successfully bill for your services, you’ll need to provide a diagnose your patients’ conditions in a manner that demonstrates the medical necessity of those services—and you’ll need to do so using the latest version of the International Classification of Diseases (ICD), which, as of October 2015, is ICD-10 . Given the complexity of the new coding system, it can be difficult to decide which code—or codes—to use. To help navigate this territory, the American Physical Therapy Association (APTA) created this shortcut list of ICD-10 categories.

If you’re ever in doubt as to whether your codes are reimbursable under your payer’s payment policy, call the payer before submitting the claim. In other words, in this case, it’s much better to ask for permission than for forgiveness.

The Current Procedural Terminology (CPT)

Developed by the American Medical Association (AMA), the Current Procedural Terminology (CPT Ⓡ ) 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-4 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.”

Most of the CPT codes that are relevant to rehab therapists are located in the 97000 section (“Physical Medicine and Rehabilitation”). However, you can bill any code that best represents the service you provide as long as you can legally provide that service under state law. Be forewarned, though: Just because you can legally bill for a code doesn’t automatically mean that a payer will reimburse you for it. When in doubt, always check with your payers before providing the service in question.

All physical and occupational therapists should get to know the following CPT categories before billing for their services. Those categories and codes include:

• 97161: PT evaluation (low complexity)
• 97162: PT evaluation (moderate complexity)
• 97163: PT evaluation (high complexity)
• 97165: OT evaluation (low complexity)
• 97166: OT evaluation (moderate complexity)
• 97167: OT evaluation (high complexity)
• PT re-evaluations (97164) and OT re-evaluations (97168)
• Supervised (untimed) modalities (97010–97028)
• Constant attendance (one-on-one) modalities (97032–97039, which are billable in 15-minute increments)
• Therapeutic (one-on-one) procedures (97110–97546)
• Active wound care management (97597–97610
• Tests and measurements (97750–97755)
• Orthotic and prosthetic management (97760–97763)

Learn more about CPT codes for physical therapists . 

One-on-One Services vs. Group Services

If you’re providing group therapy services, you should not use one-on-one CPT codes, because this can increase your risk of an audit. So, what are one-on-one services? They’re individual therapy services—ones that involve direct, one-on-one contact with a patient. During her Ascend 2015 presentation, Deb Alexander explained that these codes are cumulative, require constant attendance, and are time-based, which—as this article points out—means that the 8-minute rule applies Check out this blog post to see how many physical therapy billing units you can bill based on treatment time . 

Now, even if you’re working with more than one patient at a time, you still can provide—and bill for—one-on-one services. That’s because CMS allows these one-on-one minutes to occur continuously or in intervals—as long as those intervals are “of a sufficient length of time to provide the appropriate skilled treatment in accordance with each patient's plan of care.”

Group therapy still requires constant attendance, but it does not involve one-on-one contact with the patient. Rather, CMS writes that it “consists of simultaneous treatment to two or more patients who may or may not be doing the same activities.” So, if you’re providing attention to more than one patient at a time with only “brief, intermittent personal contact,” you should bill one unit of group therapy to each patient.

Need to get a handle on your billing processes?

Sometimes billing feels like a guessing game—one that can leave you scratching your head over claim rejections and denials. That’s why we created another physical therapists’ billing guide, the Complete Guide to Physical Therapy Billing , a comprehensive resource to help you get your billing processes in tip-top shape.

What’s the terminology?

Looking for a refresher on your billing terminology? Here are some definitions we’ve adapted from this APTA resource and this WebPT one to bring you back up to speed:

• Treatment: Includes all therapeutic services.
• Time-based (constant attendance) CPT codes: These codes allow for variable billing in 15-minute increments when a practitioner provides a patient with one-on-one services such as therapeutic exercise or manual therapy.
• Service-based (supervised or untimed) CPT codes: These are the codes therapists use to perform services such as conducting an evaluation or applying hot/cold packs. It doesn’t matter if you complete these types of treatments in 5 minutes or 45, because you can only bill one code.
• Order (a.k.a. referral): In some cases, a physician will provide an order for therapy that includes a diagnosis and instructions for treatment type, duration, and frequency.
• Evaluation: The evaluation typically takes place on the patient’s first visit and includes an examination, which consists of a review of historical data and symptoms as well as the performance of tests and measures. It is at this point that the therapist provides a diagnosis and prognosis. (Therapists should perform a re-evaluation only when the criteria detailed in this blog post are met.)
• Plan of care: Based on the evaluation—and the physician’s order, if applicable—the therapist works with the patient to develop a plan of care to help the patient meet they therapeutic goals. 
• Initial certification: Medicare requires ordering physicians to “approve or certify the plan of care via signature in a timely manner (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 receive re-certification from the ordering physician.
• Progress report: For Medicare patients, therapists must complete a progress report (a.k.a. progress note) at minimum every tenth visit.
• Discharge note: Once treatment is complete, therapists must complete a discharge progress report that outlines a patient’s progress from the last 10-visit progress note up until discharge. 

What are the forms?

Today, most payers—and providers—prefer electronic claim formats . However, some payers—a dwindling few—do still accept paper ones. The most common form is the Universal Claim Form ( CMS 1500 ), although some payers may request that you use their own. 

Once you provide your services, you’ll submit a bill to either your patient or a third-party payer. Occasionally, you may actually submit your billing information to a claims clearinghouse that will create the bill and send it out on your behalf. 

The Health Insurance Portability and Accountability Act (HIPAA) covers healthcare claims transactions, so be sure your clinic remains compliant with the Electronic Healthcare Transactions and Code Sets Standards .

What should I know about electronic claims?

No physical therapists’ billing guide would be complete without discussing electronic claim compliance. So, we thought it would be helpful to provide you with the CliffsNotes of what you need to know:

• Electronic data interchange (EDI) transactions cannot occur unless the provider has completed the EDI enrollment process , and thus has agreed to accept “responsibility for safeguarding of beneficiary data” and to also assure that any billing services or clearinghouses that they work with also has agreed to “the same security and privacy requirements required by CMS and HIPAA.”
• Furthermore, each provider must also submit a written notice to their Medicare Administrative Contractor (MAC) as part of the enrollment process to specify “which transactions a billing service or clearinghouse is authorized to submit or receive on behalf of the provider…”
• Once enrolled, providers must submit electronic healthcare claims to a MAC (a.k.a. the clearinghouse) using HIPAA-compliant software (like WebPT Billing ). The MAC will then apply the front-end edits to the claim, ensuring that they meet HIPAA standards. (If not, the MAC will reject the claims for correction and resubmission.) Once claims earn a stamp of approval from the clearinghouse, they are shipped to the insurance company to be reviewed and processed by an auditor.
• After the payer has determined the full reimbursable amount of the claim, they can transfer the funds electronically to the provider—as long as the provider is authorized to receive electronic funds transfer (EFT). There are two EFT formats Medicare contractors use to transmit payments: Automatic Clearinghouse Format (ACH) or Accredited Standards Committee (ASC) format—both are considered national standards.
• Contract agreements
• Secondary health plans
• Patient benefit coverage
• Expected copays and coinsurance
• Capitation payments
• Internal Revenue Sharing (IRS) withholding”

Once all of your digital ducks are in a row, electronic claim forms can seriously expedite payments for your clinic. In fact, it usually takes about two weeks to receive reimbursement for an electronic claim, whereas payment for paper claims can take up to six to eight weeks. And now that 99% of payers accept electronic claims, there’s no real reason you should still be submitting paper claims.

What’s the process?

Choose a software or service..

A lot of providers use a billing software to prepare and submit their claims. The really smart ones use an electronic medical record system that includes (or integrates with) a top-notch therapy billing software (hello, WebPT and Therabill ). That way, they eliminate double data entry—as well as the errors associated with it. If you go this route, be sure your solution is fully HIPAA-compliant.

You’ll also want to be sure to select a solution that offers the following key features and benefits:

• Claim tracking
• Use Electronic Remittance Advice (ERAs)
• EOB and payment posting
• Custom reports
• Clearinghouse integration
• Patient portal, invoicing, and billing
• Insurance eligibility verification
• A super-simple, user-friendly billing interface
• Detailed activity logs

To learn more about selecting the right billing software for your clinic, read this article . In case you’re wondering, even cash-based physical therapy practices need a great billing software .

In addition to everything listed above, Therabill offers credit card processing, auto-eligibility checks, a patient portal, an integrated, no-fees clearinghouse, and unlimited claims submission and support—all designed to help you get paid quickly and accurately.

See how WebPT and Therabill can help you maximize your A/R here .

If you’re looking for a more hands-off solution, you’ll want to outsource your billing to a PT-specific billing service whose team of pros will handle all of your revenue cycle management, including maximizing your reimbursements and minimizing denials. That way, you don’t have to think about beefing up your billing staff or staying on top of the often-confusing claims process.

Your practice’s financial health hinges on your ability to produce clean, accurate claims. So, you’ll want to invest in a service that can submit your claims quickly and expedite reimbursements. You’ll also want it to fully integrate with your EMR, so you can ensure a seamless workflow and no-double data entry. 

When hiring an RCM service, look for one that has:

• Experienced billers with regional specialization;
• A 98.5% first-pass claim acceptance rate; and
• A near-perfect clinic retention rate.

WebPT has 30 years of outpatient rehab therapy billing experience, making it the largest and most tenured RCM company in the industry. Our RCM team processes more than 11 million claims and visits per year. We’ve officially reached expert status. 

Click here to see how WebPT can help take your practice’s billing to the next level.

Even better: Find a rehab therapy-specific solution that prioritizes increased payment per visit and doesn’t get paid unless you do. That way, you can be sure the company will relentlessly post and reconcile payments—and investigate, correct, and appeal claim denials.

Get credentialed.

If you haven’t already received credentialing, you may want to consider changing that. Being credentialed by an insurance company allows you to become an in-network provider, which may help you reach—and serve—a larger pool of potential patients. In fact, a majority of potential patients consider whether a provider will take their insurance when making their decision on where to go for healthcare services.  And some payers— like Medicare —do not allow non-credentialed providers to treat or collect payment from patients for any covered services. However, getting credentialed isn’t exactly easy. You have to obtain:

• Malpractice insurance;
• A physical clinic location; and
• A license to practice in your state.

If you have questions about the credentialing process, consider seeking the advice of a consultant or an established PT in your neighborhood. They may be able to help you complete the paperwork as well as provide tips and tricks for ensuring its acceptance. You can also learn more about credentialing—including common pitfalls and how to avoid them— here .

Negotiate payer contracts.

Just as rules are (sometimes) meant to be broken, contracts are (always) meant to be negotiated. This especially holds true when it comes to your private payer contracts. After all, these rates establish what you’re able to earn—and that number should be an accurate reflection of the value of your services. Before you broach the subject of a rate increase with your payers, though, here are a few things you should do to ensure you’re fully prepared to get the best deal: 

• Familiarize yourself with the terms of your existing contracts, including the expiration and renewal dates as well as how far in advance you need to submit a request for modification. Some experts— like Jeff Milburn of the Medical Group Management Association —believe that providers who consistently ask for small rate adjustments each year achieve better results than those who sporadically ask for bigger bumps. And—before you sign your John Hancock on any new contracts—be sure you understand what the contract is actually saying. In other words, decipher the legalese. Check out this article to learn which phrases to be wary of.
• Identify what your clinic is receiving from your top ten payers for each CPT code; then, based on that information, set goals to help guide your negotiations.
• Create a spreadsheet for each payer that contains all of your CPT codes as well as the number of times you billed each code for that payer.
• Multiply the frequency of each code by the payment amount listed in your contract.
• To get the weighted average for that particular payer, divide the sum of your totals by the number of codes billed. Once you’ve established this number for all of your payers, you can determine which contracts are the most financially valuable to your clinic.
• Last, but definitely not least, bring in the big guns (i.e., data) to demonstrate your value. If you want to convince a particular payer that your services are worth more than you’re currently being paid for them, you best be able to back up your claim with some cold, hard, objective facts. That requires regularly and systematically collecting outcomes data, including functional improvement figures and patient and referrer satisfaction levels. Looking for an easier way to turn your outcomes data into actionable information you can really use? WebPT offers fully integrated outcomes tracking software for physical and occupational therapists.

Verify patient info.

Before you begin treatment—ideally before your patient even arrives for their first appointment—you or your front office staff members should verify patient information , including: 

• Name (with confirmed spelling)
• Date of birth
• Phone number and address
• Social Security Number (if applicable for billing insurance)
• phone number from back of card,
• the subscriber (which sometimes is not the person you’re talking to),
• the subscriber's date of birth, and
• auto insurance or workers' compensation claims (if dealing with patients either injured in an accident or receiving workers’ compensation).

It’s also a good idea to determine whether the insurance company requires a referral or preauthorization before you begin treatment.

Collect copays.

If your patient’s insurance requires them to pay a copay, you can collect that payment when you provide your services. In most cases, it is not a good idea to waive the copayment or the deductible . However, there are other ways to provide financial aid to patients who need it. To learn more about what your payers find acceptable when it comes to helping patients cover the cost of your services, thoroughly read your insurance contracts. If you can’t locate the answers in your contracts, contact the payers directly.

Issue ABNs (when applicable).

In order to provide Medicare patients with services that you believe are either not covered by Medicare or are not medically necessary, you must have your patient sign an Advance Beneficiary Notice of Noncoverage (ABN), thereby assuming financial responsibility if—but really more like when—Medicare denies the claim. To learn more about how to correctly administer an ABN, read this article .

Create defensible documentation.

Ensuring your documentation is defensible is one of the most important things you can do to support your billing processes. This will help you demonstrate medical necessity , and thus, get paid. Plus, if you ever find yourself on the wrong side of an audit, you’ll be happy you spent an extra few minutes thoroughly describing your patient’s history, your skilled interventions, and your clinical decision-making process. It’ll make a big difference in your ability to justify your requests for payment. 

Make it a team effort.

Complete and accurate billing requires a team effort, because, as we mentioned above, the billing process begins before the patient even enters your clinic—and it doesn’t end until the patient has finished their treatment and you’ve gotten paid. Here’s something you can do to ensure your team is playing like—well—a team: Teach everyone on your staff clinical terminology . It’s challenging enough to bill correctly if you’re a PT rockstar, but if you don’t understand the difference between an evaluation and an initial certification or a progress report and a re-evaluation—forget about it. Planning to work with a lot of direct access patients? You’ll need to brush up on the ins and outs of that, too—and then share your knowledge with your staff.

Still have questions about billing?

There’s always new and confusing billing scenarios cropping up in practices everywhere — which is why we host a webinar to answer your thought billing questions, featuring Heidi Jannenga and John Wallace. Check out the link below to view this year’s Billing Q&A webinar .

What are some frequently asked billing questions?

In the spirit of creating a comprehensive physical therapists’ billing guide, here are some of the most common questions PTs, OTs, and SLPs have about billing.

How do I use modifiers?

Modifier 59.

You may need to apply modifier 59 if you provide two wholly separate and distinct services during the same treatment period. An example often seen in outpatient PT settings is combining manual therapy (97140) with mechanical traction (97012). Modifier 59 would need to be applied if both of these services are provided in the same visit, with defensible documentation as to why those services were necessary.

KX Modifier

The KX modifier is part of the KX Modifier Threshold . If you believe it is medically necessary for a patient who has already reached the threshold to continue therapy—thus qualifying the patient for an exception—you would attach the KX modifier and clearly document your reasons for continuing treatment.

GA Modifier 

If you issue an ABN because you believe that certain physical therapy services are not medically reasonable and necessary, then you should add the GA modifier to the claim to signify that you have an ABN on file. (Please note that if you use the GA modifier, you should not use the KX modifier.) 

Speaking of ABN-related modifiers, there are three more you should know about :

• GX: Indicates that you issued a voluntary ABN for a non-covered service.
• GY: Indicates that you performed a non-covered service, but an ABN is not on file. (In this case, the patient is inherently liable for charges because the service is not covered.)
• GZ: Indicates that you expect the service to be denied because it isn’t medically necessary, but you do not have an ABN on file. (In this case, the patient is not responsible for payment.)

GP Modifier

Physical therapists should affix the GP modifier for services performed by a physical therapist, as opposed to another provider. This modifier is most frequently used in multidisciplinary settings. (The same goes for occupational and speech therapy plans of care.)

X Sub-Modifiers

CMS has determined for the rehab timed services codes, the -59 modifier is the appropriate modifier for NCCI edits. (You can check out Example 9 in this document for further illustration.) As of July 1, 2019, CMS has unbundled NCCI edit pairs when providers attach the appropriate modifier (59, XE, XS, XP, or XU) to either the first-column or second-column code (provided that the situation warrants the use of one of these modifiers). Like modifier 59, X sub-modifiers are intended for use when billing for two “linked” codes that are not ordinarily billed together. The difference is that X sub- modifiers offer greater specificity and thus, better justification for billing these codes together. CMS has determined that X sub-modifiers are not usually appropriate with timed CPT codes performed at separate and distinct times in a visit; in those instances, the 59 modifier would be appropriate for use.  

The four X sub-modifiers are as follows:

• XE (Separate Encounter): A service that's distinct because it occurred during a separate encounter
• XS (Separate Structure): A service that's distinct because it was performed on a separate organ/structure
• XP (Separate Practitioner): A service that's distinct because it was performed by a different practitioner
• XU (Unusual Non-Overlapping Service): A service that's distinct because it doesn't overlap the usual components of the main service

Note: CMS has since determined that the X sub-modifiers are not usually appropriate for use with timed CPT codes performed at separate and distinct times in a visit. In those cases, the 59 modifier is the most appropriate choice.

CQ and CO Modifiers

2022 marked the year the PTA and OTA payment differential went into effect. As outlined in the CMS 2022 Final Rule— and in this helpful article —the CQ and CO modifier protocols work like this:

• “When a PTA or OTA independently provides at least 10% of a service (whether that’s a timed or untimed unit), you must apply a CQ or CO modifier, respectively. 
• When a therapy assistant provides a service in tandem with a PT or OT, those minutes do not count toward the 10% de minimis benchmark. 
• If a therapy assistant furnishes more than 10% of one unit of a service, “but does not contribute to other units of that same service, then you can split the service into two different claim lines and apply CQ or CO only to the applicable units.”
• The de minimis rule (i.e., the 10% benchmark) will not apply ‘when the OT/PT provides more than the midpoint of a 15-minute timed code, that is, 8 or more minutes, regardless of any minutes for the same service furnished by the OTA or PTA.’”

What does “locum tenens” mean? 

“ Locum tenens ” means “placeholder” in Latin. In medical billing terminology, it refers to a person who temporarily fulfills the duties of another. While physicians may simply add a modifier to the treatment claim to indicate that a replacement physician provided those services, most PTs, OTs, and SLPs may not. As we explained in this blog post , “as of June 13, 2017, private practice PTs— Provider Specialty 65 —who practice in ‘non-metropolitan statistical areas, medically underserved areas (MUAs), and health professions shortage areas as defined by the US Department of Health and Human Services’ can take advantage of locum tenens arrangements.” That said, according to the APTA , even providers who meet the above-listed criteria can only “bill Medicare for services performed by a locum tenens PT under the regular PT’s NPI”—if they are “absent for a limited period of time for vacation, disability, continuing education, etc.” and the following conditions are met: 

• The regular PT is not available to provide care.
• The replacement PT is “compensated on a per diem or similar fee-for-time basis.”
• The regular PT doesn’t use locum tenens for more than 60 continuous calendar days. (If the regular PT returns to work and must leave again, they may re-hire the same locum tenens PT “and a new 60-day period begins.”)
• The PT “uses a modifier [ Q5 or Q6 ] to indicate that the services were provided by a locum tenens PT.”

It may also be important to note that in 2017, CMS decided that it would no longer refer to this type of an arrangement as “locum tenens,” yet it did not propose a replacement term. For the sake of clarity and continuity, we have decided to continue using this phrase until a better solution becomes available.

Providers who do not practice in MUAs, HSPAs, or rural areas must solve what is often referred to as the “bill as” problem by only hiring temporary employees, contractors, and travel PTs who are fully credentialed with the same insurance companies that provide benefits to their patients (and that’s especially important for Medicare). The best way to do that is usually to hire through a qualified staffing agency with verified credentials. 

Learn more about billing for temporary staff here.

What is MPPR?

In 2012, CMS began reducing payments to therapists when they performed multiple therapeutic procedures on one patient during the same date of service. This policy is known as the Multiple Procedure Payment Reduction (MPPR). During the pioneer days of MPPR—January 1, 2011, to March 31, 2013—PTs, OTS, and SLPs saw a 20% reduction to the practice expenses (PE) they billed to Medicare for these “always covered” services. Since April 2013, that figure has increased significantly, as therapists now must contend with a 50% cut to their PE when performing these services. Learn four key things you should know about MPPR here

What is the 8-Minute Rule?

The 8-Minute Rule (a.k.a. "The Rule of Eights") determines how many service units therapists can bill to Medicare for a particular date of service. According to the rule, you must provide direct treatment for at least eight minutes for each unique service in order to receive reimbursement from Medicare for time-based codes.

How do I bill for co-treatment?

There are times when co-treatment may be appropriate—specifically, when therapists of different disciplines determine that they can better address a patient’s treatment goals and needs if they provide their individual treatments during a single session. (You can find some examples here .) That said, payers have different rules for co-treatment based on coverage type and setting. We’ve compiled Medicare’s rules below; for your commercial payers, you’ll need to review your contracts and/or reach out to payers directly to learn about their rules.

Medicare Part A

When two therapists from different disciplines provide different treatments to one patient at the same time in an inpatient rehab facility, acute care setting, home health setting, or skilled nursing facility, each therapist should bill their full treatment session with that patient separately. As Meredith Castin, PT, explains in this blog post , “If an OT and a PT co-treat from 10:30 AM to 11:30 AM, and the OT works on toileting strategies while the PT simultaneously addresses safe transfers, both clinicians could bill for that entire hour, provided they show proof of providing separate treatments with separate end goals.” In all situations, though, the plan of care and documentation must support the need for co-treatment—and, as we’ll explain in a moment, the need cannot be based on provider convenience. Additionally, all providers must follow all policies regarding mode, modalities, and student supervision as well as all other federal, state, practice, and facility policies.

Medicare Part B 

By contrast, therapists who practice in facilities and clinics that bill under Medicare Part B cannot bill separately for the same or different service provided to the same patient at the same time. That means therapists must limit total billing time to the exact length of the session. In other words, the therapist of one discipline may bill for the entire service or the co-treating therapists of different disciplines may divide the service units. ASHA provides the following guidance for scenarios in which a PT or OT co-treats with an SLP: “Because SLPs usually bill treatment codes that represent a session (rather than an amount of time), and because Medicare has no published minimum/maximum session length, the SLP would bill for one untimed session.” Then, the OT or PT would bill “the timed treatment codes for the occupational or physical therapy.”

As we explained in this guide , the American Speech-Language-Hearing Association (ASHA), American Occupational Therapy Association (AOTA), and American Physical Therapy Association (APTA), developed joint guidelines for both Medicare Part A and Part B, stating that therapists should only co-treat a patient when doing so directly benefits the patient. Therapists should never co-treat for “scheduling convenience.” As Castin explained in the above-cited post, it’s important to note that while “therapists often opt to co-treat for safety reasons, simply having a second person on hand to act as a contact guard (i.e., to prevent falls) is not enough to justify billing for a second therapist's services.” Regardless of the setting, documentation for co-treatment must clearly indicate the therapists’ rationale and specify the goals each therapist is addressing. And it’s not enough for one therapist to document—even if that one therapist is billing for the entire session. Instead, both therapists should document co-treatment sessions with enough detail to convey the goals the team of therapists addressed—as well as how the patient is progressing as a result. It’s also advisable to limit therapy services performed during one treatment session to two disciplines.

Modifiers 59 and XP

Practices and facilities that offer their patients both physical and occupational therapy may need to affix modifier 59 or modifier XP to claims when patients receive same-day services that form NCCI edit pairs . According to Castin, modifier XP would be appropriate if, say, “an OT takes over treatment in the middle of a PT session” and modifier 59 would be appropriate if the payer doesn’t yet recognize X modifiers or there’s another reason to provide “otherwise linked services that should, given the circumstances, be reimbursed separately.” For example, you would use modifier 59 if, say, a PT provides gait training (97116) and an OT provides therapeutic activity (97530). As such, you’re notifying Medicare that the services—97116 and 97530—were performed separately and distinctly from one another and thus, should both be paid.

What billing behaviors should I avoid?

If you’re billing Medicare, here are a few risky behaviors to steer clear of:

• Billing for services furnished by aides or techs;
• Submitting claims for services that you know are not reasonable and necessary;
• Billing for excessive duration and frequency of services;
• Billing for unskilled prep or cleanup time;
• Billing for break times; and
• Billing for unskilled supervision. 

Learn more risky billing behaviors you should avoid here .

What should I know about ICD-10 and my billing claim forms?

• The current 1500 claim forms and the 837P (Professional) claim forms accommodate ICD-10 codes.
• You should still use CPT codes to denote services provided.
• You can list up to four diagnosis pointers per service line.
• You should order multiple diagnosis codes according to significance.
• You should never code a non-specific diagnosis with a specific diagnosis for the same problem (lest you run the risk of incurring an Exludes1 edit .
• if you believe a more accurate diagnosis code exists for a patient, don’t be afraid to contact the referring provider.

For more ICD-10 billing tips, check out this post .

When should I bill for a re-evaluation?

You should only bill for a re-evaluation if one of the following situations applies:

• You note a significant improvement, decline, or change in the patient’s condition or functional status that was not anticipated in the POC.
• You uncover new clinical findings during the course of treatment that are somewhat related to the original treating condition (i.e., a new diagnosis to add to the POC).
• The patient fails to respond to the treatment outlined in the current POC, so a change to the POC is necessary.
• You’re treating a patient with a chronic condition, and you don’t see the patient very often.
• Your state practice act requires re-evaluations at specific time intervals.

Please note that you must always update your plan of care any time you bill Medicare for a patient reevaluation.

WebPT’s co-founder and president, Heidi Jannenga, discusses this topic in great detail here.

What constitutes billable time?

In most cases, billable time is the time spent treating a patient. However, there are some notable exceptions (e.g., you can’t bill for supervision).

• You can’t bill for unskilled prep or clean-up time.
• You can bill for assessment and management time.
• You can’t bill multiple timed units due to the presence of multiple therapists.
• Rest periods and other break times are not billable.
• You can’t bill for unskilled supervision.
• “Rounding up” is a no-no .
• You can usually bill for evaluations and re-evaluations.
• You can’t always bill for documentation.

Check out this blog post to learn more about when to bill and when not to bill.

There you have it—the physical therapists’ billing guide to help you get smarter about coding and documenting your patient care to the standards set by Medicare and others in order to receive payment in a timely manner. Of course, there’s a lot more out there to know, so be sure to download The Complete Guide to Physical Therapy Billing for even more in-depth information about the ins-and-outs of codes, regulations, and more.  

Related posts

The PT, OT, and SLP’s Guide to Remote Therapeutic Monitoring

The PT, OT, and SLP’s Guide to Creating a Home Exercise Program

The Future PT’s Guide to Becoming a Physical Therapist

Learn how WebPT’s PXM platform can catapult your practice to new heights.

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Physical Therapy CPT Codes – Everything You Need to Know

Physical therapy billing and coding consists of diagnosis codes (ICD-10) and treatment codes (CPT). The ICD-10 selection tells the payer “here’s the diagnosis” and the CPT code tells the payer “Here’s the treatment – and what you need to pay for”.

Table Of Contents

• 1 Physical Therapy CPT Codes – Everything You Need to Know
• 2.1 The Two Types of Physical Therapy CPT Codes
• 2.2 Timed Codes
• 2.3 Untimed codes
• 3.1 Procedures that DO NOT REQUIRE direct one-on-one patient contact with therapist
• 3.2 The Most Commonly Used Physical Therapy CPT Codes
• 3.3 Download the Complete List of Physical Therapy CPT Codes
• 3.4 Need More Information? Contact Us
• 3.5 Need More Information about In Touch EMR? Contact Us
• 3.6 Schedule a Demo of In Touch EMR Now
• 3.7 Related Resources

The Current Procedural Terminology (CPT) code set is a medical code set maintained by the American Medical Association through the CPT Editorial Panel.The CPT code set (copyright protected by the AMA) describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.

A CPT code is a five digit numeric code that is used to describe medical, surgical, therapeutic, radiology, laboratory, anesthesiology, and evaluation/management services across the entire spectrum of medical and rehabilitation billing. In this article, we will focus on physical therapy CPT codes as they pertain to  physical therapy billing and coding . The complete list of the most common physical therapy CPT codes is very extensive, and we have done the hard work to analyze and compare medical billing software, so that we can present you with digital download file that you can access immediately, for free.

If you like, you can click the ‘Download Now’ button below to get an email with a printer-friendly version of the most commonly used physical therapy CPT codes. If you’re more interested in diagnosis codes, check out the resource on the physical therapy billing and coding cheat sheet, a guide to physical therapy ICD-10 coding.

THE DIAGNOSIS

The diagnosis sets the stage for documentation and reimbursement. Click the icon to learn more about ICD-10 coding and download a billing and coding cheat sheet.

THE TREATMENT

The right documentation, to justify the use of the most appropriate CPT codes puts you in the best position to get paid for your services. Click the icon to get examples of physical therapy documentation templates and best practices with physical therapy forms.

THE PAYMENT

The right billing and coding team will help you maximize reimbursements. Click the item to discover how to find and screen medical billing companies to help you collect the maximum possible amount from insurance companies.

The Importance of Physical Therapy CPT Codes

physical therapy CPT codes

Physical therapy CPT codes reflect what was done for that visit, and are an indication to the payer, saying “pay me for this work done”. The clinician must select the most appropriate CPT code for that encounter and make sure that documentation is compliant, and supportive of the codes that are billed out.

The best way to justify physical therapy coding with CPT codes is to enter supporting documentation in the flowsheet.

A flowsheet should be more than an exercise log. It should be a complete summary of all services rendered (procedures and modalities), duration of service (used to calculate units), extent of services rendered (repetitions, sets and duration) and supporting documentation to justify services rendered.

With In Touch EMR , supporting documentation in the flowsheet can be made mandatory, improving physical therapy billing and coding compliance. Comprehensive notes from the clinician enable auditors and payors to verify that the clinician is meeting or exceeding medical necessity for that visit.

The flowsheet is the foundation of physical therapy billing. It reveals not only what the clinician is doing and what the clinician is billing out, but also why it is being done. In the absence of supporting documentation on the flowsheet, payments for services may be withheld or recouped by payers.

Every time that the patient is seen, it is important to enter supporting documentation to justify the ongoing medical need for therapy services. The question “Why are you continuing to see the patient?” has to be answered conclusively with every flowsheet.

Meeting medical necessity is an ongoing process. As a physical therapy billing best practice, supporting documentation should be distinct and unique for each visit.

Physical therapy CPT codes may also be associated with two digit modifiers, used to clarify or modify the description of the procedure. Adding a modifier to a CPT code line item is saying to the payer “There are some special circumstances related to this treatment, and these codes provide more information and / or impact the payment for these line items”.

The Two Types of Physical Therapy CPT Codes

There are two types of CPT codes used in physical therapy coding: time codes and untimed codes.

Timed Codes

Physical therapists bill one unit for the first 15 minutes of treatment for most timed codes. Additional units can be billed based on the duration of the treatment time. The longer the treatment time, the higher the number of units that can be billed.

Untimed codes

Procedures that require direct one-on-one patient contact with therapists.

In the same 15-minute (or other) time period, a 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 above – (CPT codes 97032- 97542).
• For example: Any CPT code for a therapeutic procedure (example: 97116-gait training) with any attended modality CPT code (example: 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 reeducation (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 reevaluation 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)

Procedures that DO NOT REQUIRE direct one-on-one patient contact with therapist

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.

The Most Commonly Used Physical Therapy CPT Codes

Most physical therapists believe there are only a handful of cpt codes that can be billed out by physical therapists. The fact is, there are almost 600 physical therapy cpt codes that can be billed out. However, it is true that a small number of them (approximately 30) are the most used physical therapy cpt codes. They are listed in green, and in blue below.

Before you review this list, please note that physical therapy billing and physical therapy coding practices vary from one clinic to another. As a clinician, you always want to bill the most appropriate CPT codes for that encounter, and your clinical judgement and supporting documentation should justify the use of the physical therapy CPT codes that are being billed out.

We have tried to make this list as comprehensive as possible, but we recommend you identify the specific CPT codes that are applicable to your practice and conduct your own research as well.

Green = Most Common (20 codes)

Blue = Somewhat Common (10 codes)

Red = Least Common (574 codes)

This is a total of 604 CPT codes. You can download the entire list of the most commonly used physical therapy CPT codes by clicking on the button below.

MOST COMMON

Physical therapy evaluation

Physical therapy re-evaluation

Occupational therapy evaluation

Occupational therapy re-evaluation

Application of a modality to 1 or more areas; traction, mechanical

Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes

Application of a modality to 1 or more areas; ultrasound, each 15 minutes

SOMEWHAT COMMON

Application of a modality to 1 or more areas; vasopneumatic devices

Application of a modality to 1 or more areas; paraffin bath

Application of a modality to 1 or more areas; ultraviolet

Application of a modality to 1 or more areas; contrast baths, each 15 minutes

Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes

Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG

and/or manometry

Click ‘Download Now’ for the COMPLETE list

LEAST COMMON

Application of a modality to 1 or more areas; iontophoresis, each 15 minutes

Therapeutic procedure(s), group (2 or more individuals)

Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minute

Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes

Download the Complete List of Physical Therapy CPT Codes

The selection of these CPT codes is very important, since it reflects what procedures / modalities were provided for that visit. This determines how much you get paid. Therefore, it is crucial that you bill out the most appropriate CPT codes at all times.

CMS 1500 form modifier requirements as of Jan. 1, 2014 require that all therapy codes billed on the CMS 1500 form must use modifiers consistent with Medicare rules to distinguish the discipline of the plan of care.

The GP modifier indicates services delivered under an outpatient physical therapy plan of care and the GO modifier indicates services delivered under an outpatient occupational therapy plan of care.

In reviewing the above list, it’s easy for CPT coding to become a bit overwhelming.

That’s why it’s important to have physical therapy billing and coding specialists working to ensure your claims are properly coded (in fact, many physical therapists under-bill their services.).

It is also helpful to download and review the entire list of the most commonly used physical therapy CPT codes. Click here to download the complete list of physical therapy CPT codes.

Need More Information? Contact Us

In Touch Billing provides billing and coding services with an expert team of physical therapy coders.  In Touch Billing has an average first pass rate 8% higher than industry standard, with costs averaging 2% lower.

Schedule a discovery call today to get your no obligation billing quote from In Touch Billing.

In Touch Billing is one of the few medical billing companies offering unlimited support via phone, email and live chat, and we guarantee to lower your medical billing costs, and provide you with outstanding customer service.

Click here to schedule a free ‘billing strategy’ call with the experts at In Touch Billing, or call (800)-421-8442 to learn more.

To get an overview of all the services at In Touch Billing, watch this video below:

Need More Information about In Touch EMR? Contact Us

In Touch EMR is a fully integrated scheduling, documentation and billing software for physical therapy practices. It is a simple and user friendly web-based, ICD-10 and HIPAA compliant EMR, and it offers customizable templates for notes, the ability to attach files, electronic signatures, and the ability to track progress notes, treatment plans, and assessments.

Click here for answers to your most frequently asked questions about EMR selection and transition.

In Touch EMR has grown to over 1000 clients, our company / founders have been mentioned on CNN, Forbes, Huffington Post, Amazon, received the prestigious ONC certification, 2015 and 2016 PQRS registry designation, integrated with Microsoft’s cutting edge patient portal technology and initiated groundbreaking healthcare partnerships with companies like Novartis. All of this is possible thanks to clients across the country, who have embraced In Touch EMR.

In Touch EMR is featured on our HIPAA compliant hosting partner (Amazon Web Services) website along with other industry leaders such as the Cleveland clinic, Nexttech, Saint Mary’s regional medical center and UCLA health.

SIMPLE, TRANSPARENT PRICING MODEL

At In Touch EMR, we charge a flat fee per licensed clinician (no hidden fees or surprises) and it includes everything, unlimited claims and notes and infinite custom template creation. We are also a CMS recognized PQRS registry, we automate the reporting of PQRS and Functional Limitation G codes and provide automatic alerts for plan of care expirations, authorizations, progress note reminders and KX modifier alerts.

Clients also get a self-paced video training program on how to get up and running, custom documentation template builder, unlimited patient manager and patient portal.

Every license unlimited ongoing support (phone / email / live chat), billing software integration, unlimited appointments, unlimited documentation, unlimited document uploads and unlimited electronic faxing.

OFFICE OF THE NATIONAL COORDINATOR CERTIFIED ELECTRONIC HEALTH RECORD TECHNOLOGY

We are a premier vendor in the rehabilitation space, and on the prestigious, certified Health IT Product List, which is a division of the office of the National Coordinator for Health Information Technology, a division of the Department of Health and Human Services.

Very few vendors can make this claim, and they generally won’t bring this up (in some cases, out of ignorance) mostly because this is not a mandatory certification, it is optional and requires a significant investment of time and effort. This certification is a sign of our commitment to a HIPAA compliant, secure and stable EMR system for your clinic.

If you ever get audited, the fact that you are using ONC-certified EHR technology (CEHRT) will work in your favor. CMS looks favorably on the use of CEHRT since HHS is trying to encourage the adoption of CEHRT amongs providers nationwide as part of a long term push towards electronic documentation and interoperability between EMR systems. Your practice can state that it carefully vetted and selected “a rehabilitation-specific vendor that passed  all of the ONC HIT 2014 Edition EHR Certification criteria required to satisfy the Base EHR definition”

Since In Touch EMR has been very proactive at staying at the forefront of emerging guidelines for EMR vendors, you are assured higher quality, higher security and more compliance with CMS and other payer regulations.

For more information about the ONC, please visit: http://www.healthit.gov/newsroom/about-onc

In Touch EMR is one of the only EMR vendors in the rehabilitation space to pass all the 2014 Edition EHR Certification criteria required to satisfy the Base EHR Definition as stated by the Office of the National Coordinator for Health Information Technology, as listed here: http://www.healthit.gov/sites/default/files/pdf/BaseEHR_8-18-12_Final.pdf

In Touch EMR is on the Certified Health IT Product List (CHPL) website.

http://www.healthit.gov/policy-researchers-implementers/certified-health-it-product-list-chpl

PRAISE FROM THOUSANDS OF SATISFIED CLINICS ACROSS THE UNITED STATES

“In Touch EMR has emerged as a comprehensive, customizable EMR solution for our growing organization. Support is always there when we need it, options to customize options to match our workflow are endless, clinicians find it simple and easy to use, front desk and billing love the integration between documentation and claims and compliance is built-in. This is exactly what we needed and it has boosted our efficiency. Couldn’t have asked for more. In Touch EMR is a leader in web-based EMR for our practice. Thank you!”

Julie Edelman PT, DPT – Avanti Therapy

“Moving to In Touch EMR was a process of adjustment, but it was worth it, for several reasons. Not only has the staff at In Touch EMR been proactive in adding new features and responding to support calls and streamlining our billing processes, they have been understanding, professional, polite and patient. The ability to create our own documentation templates, generate professional reports on demand and submit claims to billing with one click has allowed us to streamline our practice. The billing software is extremely versatile – I can review number of claims sent / on hold, payer breakdown, charges per visit and collections per visit. Our biller is able to pull up detailed reports, exactly the way we want. My front desk staff has the ability to track authorizations and create progress note alerts, physician prescription alerts and fax reports to physicians with the click of a button in In Touch EMR. My management is now exploring analytics to identify areas of growth and efficiency and expect to drive our practice further with analytic insights. Best of all, the transition for our entire staff was streamlined and consistent and help was readily available. I like that we are able to talk to someone whenever we need to. If you are looking for a powerful, reliable, and responsive team to help you implement EMR and billing software to grow your practice, look no further than the team at In Touch EMR. We support this therapist owned EMR company wholeheartedly.”

Matthew S. Fischer, MSPT – Fischer Physical Therapy

“In my 30+ years as a compliance auditor, author and instructor, I have yet to see an EMR and billing software as comprehensive as In Touch EMR. If you are looking for compliant ICD-10 documentation, and a ‘gold standard’ that can survive auditing, get In Touch EMR. A well defined workflow for the front desk, clinicians, billers and coders makes this a one-stop shop for quick, compliant documentation and flawless billing. I’m impressed with their HIPAA compliance, PHI protection and data breach prevention protocols. The front desk automation (certification alerts, patient portal, birthday reminders, e-newsletters) and clinician automation (progress note and reevaluation countdown, autotext technology, flowsheet templates, tasks and messages) are sufficient to set them apart. They didn’t stop there. The billing automation (claim cleanser, automatic transmission to billing, CCI edits – modifier 59 automation, autopost ERAs) and the administrator functions (access controls, audit logs, time tracking, productivity metrics) result in an incredible EMR and billing software combination for all clinicians. It’s a no brainer – forget the hype from other products and get In Touch EMR”

Cheryl House RMC, CHI  Compliance Auditor, Author, Coder and Instructor at Illinois Valley Community College

“I was looking for a Practice Management Software that combined both documentation and billing platform systems that work in unison. I had previously tried more complicated systems that made me exhausted at the end of the day. In Touch EMR and In Touch Biller Pro represent a united and unified package that helps the private practice clinician govern a practice. It’s easy to use, it is concise, and it has a plenty of analysis variables to study.”

Sammy K. Bonfim PT – Rehabilitation & Performance Center

All In Touch EMR customers get unlimited support via phone, email and live chat.

Click below to schedule a free demo with the experts at In Touch EMR, or call (800)-421-8442 to learn more.

Schedule a Demo of In Touch EMR Now

At In Touch EMR, we charge a flat fee per licensed clinician (no hidden fees or surprises) and it includes everything, unlimited claims and notes and infinite custom template creation. We are also a CMS recognized PQRS registry, we automate the reporting of PQRS and Functional Limitation G codes and provide automatic alerts for plan of care expirations, authorizations, progress note reminders and KX modifier alerts. Schedule a demo to see why practices across the country are switching to In Touch EMR.

Related Resources

Physical Therapy Coding Cheat Sheet – Your Definitive Guide to Physical Therapy ICD-10 Coding

What to Look for in Physical Therapy Software

Ten Ways to Speed Up Physical Therapy Documentation

Skilled Physical Therapy Documentation – In Touch EMR Vs OptimisPT Physical Therapy Software

Physical Therapy Documentation Examples (Downloadable) and Best Practices with Physical Therapy Forms

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Top physical therapy cpt codes - plus printable reference sheet.

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.

Are you looking for a guide to telehealth billing codes? Check out our quick guide to telehealth billing and reimbursement for physical therapy!

The 11 most common physical therapy cpt codes.

• 97110: Therapeutic Exercise
• 97112: Neuromuscular Re-education
• 97116: Gait Training
• 97140: Manual Therapy
• 97150: Group Therapy
• 97530: Therapeutic Activities
• 97535: Self-Care/Home Management Training
• 97750: Physical Performance Test or Measurement
• 97761: Prosthetic Training
• 292**, 295**: Strapping
• 90901, 90911: Biofeedback

Most of the new edits have been to the “Common CPT Codes and Their Usage” section , where you'll find expanded descriptions and other helpful updates.

While most of us got into this profession for the pure enjoyment of working with people who need our help, money still controls our profession, as it does in any other field.

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 . Aetna alone reported a revenue of over $60.3 billion in 2015, a record for the company despite insurance companies sobbing over the passing of the Affordable Care Act in 2010.

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.

Want more information on physical therapy billing and the 8 minute rule ? We've broken it down even further.

Untimed codes: The PT is paid a predetermined fee regardless of the time of treatment application or the number of body areas being treated. 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.

Common Physical Therapy CPT Codes and Their Usage

97110 Therapeutic Exercise: Includes exercises for strengthening, ROM, endurance, and flexibility and must be direct contact time with the patient. 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. Insurance companies assume that we can provide therapeutic exercise without us being very hands-on with the patient (think riding a recumbent bike).

97112 Neuromuscular Re-education: Activities that facilitate re-education of movement, balance, posture, coordination, and proprioception/kinesthetic sense. 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 may include sit-to-stand training, bed mobility, step-ups/stair negotiation, hip-hinge training, squatting mechanics , throwing a ball, swinging a bat or golf club, car transfer training, and training proper lifting mechanics.

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. For this reason, they require more skilled intervention on our part.

97535 Self-Care/Home Management Training: This includes ADL training, compensatory training, going over safety procedures/instructions, meal preparation, and use of assistive technology devices or adaptive equipment. You can also use this code for teaching wound care techniques, strategies for edema control, safe sleeping positions, use of a home tens unit, traction, or paraffin device, activity modification, setting up a safe home environment, basic household cleaning/chores, and for education on the signs of infection. You can also include transfer/transition training in this code if the patient is having trouble getting up out of a chair, but not if you are using sit to stand for strengthening.

The six basic ADLs are :

• Transferring

As long as you are working on any of these activities with your patient’s exercise program, you can bill this code. Some of these exercises may include functional IR and ER training (dressing, toileting), fine motor skills (manipulating utensils), pelvic floor muscle exercises (for continence), sit to stand, and improving posture/deep cervical flexor endurance to ensure safe and effective swallowing.

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. The following tests and measures would be suitable:

• Functional capacity evaluations
• Functional assessments
• Cybex testing
• Sensory/pinch/grip tests
• Sport-specific tests
• Video analysis of gait, throwing, or running
• Exertional testing

You can argue that using a goniometer to measure joint range of motion or using manual muscle testing/ergometry would fall under this category as well since they are a piece of the “functional” puzzle, however, I have never used this code for this reason. I would use this code if I decided to administer the Berg Balance Scale (functional assessment) at any point after my initial evaluation.

97761 Prosthetic Training: Includes fitting and training in the use of prosthetic devices as well as assessment of the appropriate device, but does not include fabrication time.

97762 Checkout for Orthotic/Prosthetic Use: Includes evaluation of the effectiveness of an existing orthotic or prosthetic device and recommendation for change.

292**, 295** Strapping: One of the more debatable CPT codes being used by PTs is the set of strapping codes. 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.

Further Useful (but Less Common) Physical Therapy CPT Codes

• 97010: Hot or cold packs therapy
• 97012: Mechanical traction therapy
• 97014: Electric stimulation therapy
• 97016: Vasopneumatic device therapy
• 97018: Paraffin bath therapy
• 97022: Whirlpool therapy
• 97026: Infrared therapy
• 97028: Ultraviolet therapy
• 97032: Electrical stimulation
• 97033: Electric current therapy
• 97034: Contrast bath therapy
• 97035: Ultrasound therapy
• 97036: Hydrotherapy
• 97039: Physical therapy treatment
• 97113: Aquatic therapy/exercises
• 97124: Massage therapy
• 97127: Therapeutic interventions with a focus on cognitive function
• 97139: Physical medicine procedure
• 97151: Behavioral identification assessment
• 97153: Adaptive behavior treatment by protocol
• 97154: Group adaptive behavior treatment by protocol
• 97155: Adaptive behavior treatment by protocol (modification)
• 97156: Family adaptive behavior treatment guidance
• 97157: Multi-family adaptive behavior treatment guidance
• 97158: Group adaptive behavior treatment
• 97161: PT evaluation, low complexity, 20 minutes
• 97162: PT evaluation, moderate complexity, 30 minutes
• 97163: PT evaluation, high complexity, 45 minutes
• 97164: PT re-evaluation
• 97750: Physical performance test
• 97755: Assistive technology assessment
• 97760: Orthotic management and training, first encounter
• 97761: Prosthetic training, first encounter
• 97763: Orthotic/prosthetic management, subsequent encounters

Common Billing Blunders

Fixed rate payers: These payers reimburse using a capped daily maximum payment. 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.

• 7 Deadly Sins of Physical Therapist Coding and Billing. (2017, March 09). Retrieved June 18, 2017, from https://www.bmspracticesolutions.com/7-deadly-sins-of-physical-therapist-coding-and-billing/
• Biofeedback Services. (2019, June 27). Retrieved from https://www.cms.gov/
• CPT® Purpose & Mission. (n.d.). Retrieved June 15, 2017, from https://www.ama-assn.org/practice-management/cpt-purpose-mission
• Gardner, K. (n.d.). Coding for Interventions (CPT-4). Retrieved June 15, 2017, from http://www.apta.org/Payment/Coding/Interventions/
• Guide to Physical Therapist Practice. (n.d.). Retrieved June 15, 2017, from http://guidetoptpractice.apta.org/
• Health Insurance Industry Rakes in Billions While Blaming Obamacare For Losses. (2017, February 21). Retrieved June 15, 2017, from https://www.consumeraffairs.com/news/health-insurance-industry-rakes-in-billions-while-blaming-obamacare-for-losses-110116.html
• Insurance Company Profitability. (2015, December 03). Retrieved June 15, 2017, from http://www.insurancejournal.com/magazines/features/2015/12/07/390548.htm
• Medicare vs AMA Billing Guidelines. (2015, November 25). Retrieved August 23, 2019, from https://www.webpt.com/blog/post/the-8-minute-rule-showdown-medicare-vs-ama
• The 8-Minute Rule: What it is and How it Works in WebPT. (2014, April 09). Retrieved June 15, 2017, from https://www.webpt.com/blog/post/8-minute-rule-what-it-and-how-it-works-webpt

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(2023) Physical Therapy CPT Codes & Billing Guidelines

Physical therapy is a service to restore patients healthy through physical activities. CPT 97161 , CPT 97162 , CPT 97163 , CPT 97164 and CPT 97140 can be reported for physical therapy evaluation.

For home health physical therapy CPT G0151 , CPT G0157 & CPT CPT G0158 can be reported.

CPT 97014 can be reported for the application of a modality, CPT 97535 for self care management training and compensatory training, CPT 97112 for neuromuscular reeducation and CPT 97530 for therapeutic activities to improve functional performance with dynamic activities.

CPT 90912 and CPT 90913 can be reported for pelvic floor dysfunction physical therapy.

Coding Guidelines For Physical Therapy CPT Codes

The physical therapy CPT codes can be billed for services provided by a therapist to maintain or restore patient health through physical activities.

To provide these services, AMA has provided the guidelines how to perform and bill physical services.

A physician or therapist would need to provide evaluation before establishing therapeutic therapy or medication therapy.

A physician can bill E&M services when providing evaluation but for physical therapist, we have different codes.

Physical Therapy Evaluation CPT Codes

Evaluation in physical therapy is a dynamic process in which the physical therapist makes clinical judgments based on data gathered during examination.

Examination does include conducting a comprehensive history, by performing a systems review, and directing tests and measures.

After that, physical therapist or physician evaluates the findings of examination, do establish any physical therapy diagnosis if identified properly, determine the prognosis and then develop complete plan care that include future goals and expected or unexpected outcomes, interventions to be used and anticipated plans for conclusion of care.

Underneath are the coding guidelines for physical therapy evaluation.

Coding Guidelines

Medicare requires a re-evaluation after every nine visits. Time codes are billed typically with an 8-minute rule and the number of units depends on the time duration that is spent during an encounter.

There are basically three different levels of physical therapy evaluation: one is low, second moderate, and third is high complexity.

The level of evaluation performed is dependent on the degree of clinical decision making and on the severity of the patient’s condition.

The following CPT codes can be used for physical therapy evaluation : CPT 97161 , CPT 97162 , CPT 97163 & CPT 97164 .

97161 CPT Code Description

CPT code 97161 can be used for physical therapy evaluation of low complexity.

Complexity: Low Time: 20 minutes How: Face-to-face with the patient or/and family of the patient

TIP : You can find the complete billing guide for CPT 97161 here.

97162 CPT Code Description

CPT 97162 can can be reported for physical therapy evaluation.

Complexity: Moderate Time: 30 minutes How: Face to face with the patient or/and family of patient

97163 CPT Code Description

CPT 9763 can be reported for physical therapy evaluation.

Complexity: High Time: 45 minutes How: Face to face with the patient or/and family of patient

97164 CPT Code Description

If there is a requirement for the re-evaluation of a patient, CPT 97164 should be used. This CPT code is used for the re-evaluation of physical therapy established plan of care.

Time: 20 minutes How: Face to face with the patient or/and family

97140 CPT Code Physical Therapy

The 97140 CPT code can be used for manual physical therapy techniques for 1 or more regions.

Time: 15 minutes

This CPT code can be reported for:

• manual-traction;
• manual lymphatic drainage;
• mobilization;
• manipulation.

Read more about the 97140 CPT code here.

Physical Therapy CPT Codes 2020

Services which are performed by physical therapist are billed with the following 2020 CPT codes.

• Therapeutic modalities, PT and OT both use these codes: CPT 97110 – CPT 97546
• Supervision services mostly: CPT 97010 – CPT 97028
• Physical Performance Test or Measurement: CPT 97750
• Prosthetic Training: CPT 97761
• Checkout for Orthotic/Prosthetic Use: CPT 97762

Home Health Physical Therapy CPT Codes

Three CPT codes can be used for physical therapy. We have written about the CPT codes for home health physical therapy before. CPT G0151 is used for therapists and CPT G0157 for assistant therapist. The G0159 CPT code is used when there is establishment of therapy program is taken place in home or hospice setting.

CPT Code G0151

Services performed by a qualified physical therapist.. Read More..

CPT Code G0157

Services performed by a qualified physical therapist assistant in.. Read More..

CPT Code G0159

Services performed by a qualified physical therapist, in the home health.. Read More..

97014 CPT Code Physical Therapy

CPT 97014 can be reported for the application of a modality to 1 or more areas; electrical stimulation (unattended).

Description & Guidelines

In order to bill the 97140 CPT code ; the health care provider has to apply electrical stimulation to one or more areas in order to stimulate muscle function, enhance healing and alleviate pain or/and edema .

The clinician can choose the type of electrical stimulation is appropriate. The treatment requires supervision and typically only one session is reported per day.

However, when multiple separate treatment sessions are performed per day, it is appropriate to report each treatment session.

CPT 97140 can require Modifier 76 if two separate treatment sessions are provided on the same date of service (e.g., a.m. and p.m.).

Both CPT codes may be reported but would require modifier 76 to indicate that the service-based code (not the time descriptors) is being reported for two separate sessions on the same date.

97535 CPT Code Physical Therapy

CPT 97535 can be used to report self-care management training and compensatory training. We have written a separate article with coding guidelines about the 97535 CPT code.

Description

Self-care/home management training and compensatory training, meal preparation, safety.. Read more..

97112 Physical Therapy Code

CPT 97112 can be used to report Neuromuscular Re-education ( Therapeutic procedure). We have written an article about the 97112 CPT code with coding guidelines .

Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular.. Read More..

97530 Physical Therapy Code

CPT 97530 can be reported for therapeutic activities to improve functional performance with dynamic activities. We have written an article with coding guidelines for the 97430 CPT code.

Therapeutic activities, direct (one-on-one) patient.. Read More..

Worker Comp Physical Therapy Services

When an injury or illness is work related, a patient would want you to bill the services to WC carrier rather normal primary healthcare insurance.

In case of physical therapy, you would usually need to take prior authorizations for services a physical therapist is going to perform.

The codes for physical therapy for WC are the same process and the amount paid to the therapist can vary.

CPT Codes For Pelvic Floor Dysfunction Physical Therapy

CPT 90912 and CPT 90913 can be reported for pelvic floor dysfunction and physical therapy. Physical therapy services are performed to restore the function of the pelvic floor.

Documents should clearly document the service as per performed like “pelvic muscles exercise/therapy”. The codes that are used section biofeedback training for billing purposes. These exercises are provided mainly for urinary incontinence.

What is Biofeedback?

Biofeedback trains patients to control their autonomic or involuntary nervous system responses to regulate vital signs, like heartrate, blood pressure, temperature, and muscle tension.

This code has been updated for providers to bill biofeedback training for monitoring muscles specifically of the anus, rectum, perineum, GI tract, and urethral sphincter.

Electromyography , which measures muscle contractions, and/or manometer to measure pressure are included when performed.

This particular biofeedback training is done to help the incontinent patient gain control of the related muscles.

CPT 90912 Description

Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG or/and manometer.

Time:  15 initial minutes How: One on one professional contact Performed by: physician or other qualified health care professional

The 90912 CPT code in an additional code that can be reported for each additional 15 minutes.

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Simplified guidelines for coding and documenting evaluation and management office visits are coming next year. Learn how to apply the guidelines to some common visit types.

CAROL SELF, CPPM, CPC, EMT, KENT MOORE, AND SAMUEL L. CHURCH, MD, MPH, CPC, FAAFP

Fam Pract Manag. 2020;27(6):6-11

Author disclosures: no relevant financial affiliations disclosed.

Editor's note: In its 2021 Medicare Physician Fee Schedule, CMS released new guidance regarding coding for prolonged E/M services. This article has been updated accordingly.

The American Medical Association (AMA) has established new coding and documentation guidelines for office visit/outpatient evaluation and management (E/M) services, effective Jan. 1, 2021. The changes are designed to simplify code selection and allow physicians to spend less time documenting and more time caring for patients. Physicians and other qualified health professionals (QHPs) will be able to select the level of office visit using either medical decision making (MDM) alone or total time (excluding staff time) on the date of service. In addition, the history and physical exam will be eliminated as components of code selection, and code 99201 will be deleted (code 99211 will not change). (See “ E/M coding changes summary .”)

To follow up on the previous FPM article detailing these changes (see “ Countdown to the E/M Coding Changes ,” FPM , September/October 2020), we have applied the 2021 guidelines to some common types of family medicine visits, and we explain below how documentation using a typical SOAP (Subjective, Objective, Assessment, and Plan) note can support the chosen level of service.

In each vignette, we've arrived at a code based only on the documentation included in the note. It's possible that a more extensive note could support a higher level of service by further clarifying the physician's decision making. But we've analyzed each case through an auditor's lens and tried not to make any assumptions that aren't explicitly supported by the note.

Starting in January, physicians and other qualified health professionals will be able to select the level of office visit using either medical decision making alone or total time (excluding staff time) on the date of service.

Medical decision making is made up of three factors: problems addressed, data reviewed, and the patient's risk. The highest level reached by at least two out of three determines the overall level of the office visit.

If the visit was time-consuming, but the medical decision making did not rise to a high level, the physician or qualified health professional may want to code based on total time instead.

MEDICAL DECISION MAKING (MDM)

Starting in January, physicians will be able to select the level of visit using only medical decision making, with a revised MDM table. (See the table at https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf .)

The four levels of MDM (straightforward, low, moderate, and high) will be maintained but will no longer be based on checkboxes or bullet points. The level of service will be determined by the number and complexity of problems addressed at the encounter, the amount and complexity of data reviewed and analyzed, and the patient's risk of complications and morbidity or mortality.

Here's what that looks like in practice:

STRAIGHTFORWARD MDM VIGNETTE

An established patient presents for evaluation of eye matting. The documentation is as follows:

Subjective: 16 y/o female presents with a 2-day history of bilateral eye irritation. She denies any fever or sick contacts. She started having a slight runny nose and cough this morning. She thinks the matting is a little better than yesterday. She wears daily disposable contacts but hasn't used them since her eyes have been bothering her. Her younger sibling has had similar symptoms for a few days.

Objective: Temperature 98.8, BP 105/60, P 58.

General: No distress. Does not appear ill.

HEENT: Mild bilateral conjunctival erythema without discharge. No tenderness over eye sockets. EOMI, PERRL.

Neck: No cervical lymph nodes palpated.

Lungs: Clear to auscultation.

Assessment: Viral conjunctivitis.

Plan: Reviewed likely viral nature of symptoms. Supportive and conservative treatment options reviewed, including eye cleaning instructions and contact lens precautions. Call the office if symptoms persist or worsen. Avoid use of contacts until symptoms resolve.

CPT code: 99212.

Explanation: Under the 2021 guidelines, straightforward MDM involves at least two of the following:

Minimal number and complexity of problems addressed at the encounter,

Minimal (in amount and complexity) or no data to be reviewed and analyzed,

Minimal risk of morbidity from additional diagnostic testing or treatment.

This is the lowest level of MDM and the lowest level of service physicians are likely to report if they evaluate the patient themselves (code 99211 will still be available for visits of established patients that may not require the presence of a physician).

In this fairly common scenario, the assessment and plan make it clear that the physician addressed a single, self-limited problem (“minimal” in number and complexity, per the 2021 MDM guidelines) for which no additional data was needed or ordered, and which involved minimal risk of morbidity.

Per the 2021 CPT guidelines, “For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated.” In this case, there is little risk of morbidity to this patient from the viral infection diagnosed by the physician.

It's possible the physician considered prescribing an antibiotic in this case, but decided against it. Options considered but not selected can be used as an element for “risk of complications,” but they should be appropriate and documented. There is no documentation in this note to indicate the physician made that decision. The documentation provided, therefore, does not support a higher level of service using MDM. But if the physician did make that decision and the ensuing conversation with the patient was time-consuming, the physician always retains the option to choose the level of service based on time instead.

LOW LEVEL OF MDM VIGNETTE

An established patient presents for follow-up for stable fatty liver. The documentation is as follows:

Subjective: 62 y/o female presents for follow-up of nonalcoholic fatty liver. She has no other complaints today and no other chronic conditions. She denies any fever, weight gain, swelling, or skin color changes. She also denies any confusion. She continues to work at her regular job and reports no difficulties there. She denies any unusual bleeding or bruising. Energy is good. Diagnosis was made three years ago, incidentally, on an ultrasound. Condition has been stable since the initial full evaluation.

Objective: BP 124/70, P 76, Temperature 98.7, BMI 26.

General: Well-appearing. Alert and oriented x 3.

Eyes: Sclera nonicteric.

Heart: Regular rate and rhythm; trace pretibial edema.

Abdomen: Soft, nontender, no ascites, liver margin not palpable.

Skin: No bruising.

Labs reviewed and analyzed: CBC normal, CMP with elevated AST (62 IU/ml) and ALT (50 IU/ml), PT/PTT normal.

Last ultrasound was 3 years ago.

Assessment: Nonalcoholic steatohepatitis, stable.

Plan: LFTs continue to be improved since initial diagnosis and 30-pound intentional weight reduction. Continue monitoring appropriate labs at 6-month intervals. Follow up in 6 months, or sooner if swelling, bruising, or confusion. Avoid alcohol. Continue weight maintenance. She is reassured her condition is stable and has no other questions or concerns, especially in light of her prior extensive education on the topic. I am arranging for hepatitis A and B vaccination. Discussed OTC medications, including vitamin E, and for now will avoid them.

CPT code: 99213

Explanation: Under the 2021 guidelines, low-level MDM involves at least two of the following:

Low number and complexity of problems addressed at the encounter,

Limited amount and/or complexity of data to be reviewed and analyzed,

Low risk of morbidity from additional diagnostic testing or treatment.

In this vignette, the patient has one stable chronic illness, which is an example of an encounter for problems low in number and complexity. The risk of complications from treatment is also low. The “Objective” section indicates review of three lab tests, which qualifies as a moderate amount and/or complexity of data reviewed and analyzed. However, the level of MDM requires meeting two of the three bullets above, so the overall level remains low for this vignette.

MODERATE LEVEL OF MDM VIGNETTE

An established patient with obesity and diabetes presents with new onset right lower quadrant pain. The documentation is as follows:

Subjective: 42 y/o female presents for evaluation of 2 days of abdominal pain. She has a history of Type 2 diabetes, controlled. Pain is moderate, 6/10 currently, and 10/10 at worst. The pain is intermittent. The pain is located in the back and right lower quadrant, mostly. She denies diarrhea or vomiting but does note some nausea. She denies fever. She denies painful or frequent urination. She is sexually active with her spouse. She has had a hysterectomy due to severe dysfunctional bleeding. She has not tried any medication for relief. No position seems to affect her pain. She has not had symptoms like this before. Home glucose checks have been in the 140s fasting. Her last A1C was 6.9% two months ago. Family history: Sister with a history of kidney stones.

Objective: BP 160/95, P 110, BMI 36.1.

General: Appears to be in mild to moderate pain. Frequently repositioning on exam table.

HEENT: Moist oral mucosa.

Abdomen: Mild right-sided tenderness. No focal or rebound tenderness. Normal bowel sounds. No CVA tenderness. No suprapubic tenderness. No guarding.

UA with microscopy: 3 + blood, no LE, 50–100 RBCs, 5–10 WBCs.

CBC, CMP, CT stone study ordered stat.

Assessment: Abdominal pain – suspect renal stone. Also consider cholecystitis, gastroparesis, gastroenteritis, appendicitis, and early small bowel obstruction.

Diabetes, type 2, controlled.

Obesity – this is a risk factor for gall-bladder problems, but still favor renal stone.

Plan: Ketorolac 60 mg given in office for pain relief. Hydrocodone/APAP prescription for pain relief. Discussed at length suspicion of renal stone. Will plan lab work and pain control and await CT stone study. Urine sent to reference lab for microscopy. Drink plenty of fluids. Urine strainer provided. Call the office if worsening or persistent symptoms. Await labs/CT for next steps of treatment plan. Will follow up with her if urology referral is indicated.

CPT code: 99214

Explanation: Under the 2021 guidelines, moderate level MDM involves at least two of the following:

Moderate number and complexity of problems addressed at the encounter,

Moderate amount and/or complexity of data to be reviewed and analyzed,

Moderate risk of morbidity from additional diagnostic testing or treatment.

In this vignette, the patient has one undiagnosed new problem with uncertain prognosis (abdominal pain) and two stable chronic conditions (diabetes and obesity). Either one (the new problem with uncertain prognosis or two stable chronic conditions) meets the definition of a moderate number and complexity of problems under the 2021 MDM guidelines. But they do not meet the threshold of a high number and complexity of problems, even when combined.

The physician reviews or orders a total of four tests, which again exceeds the requirements for a moderate amount and/or complexity of data, but doesn't meet the requirements for the high category.

The prescription drug management is an example of moderate risk of morbidity. One might argue that the risk of morbidity is high because renal failure could result from a major kidney stone obstruction. But even then the overall MDM would still remain moderate, because of the number and complexity of problems addressed and the amount and/or complexity of data involved.

HIGH LEVEL OF MDM VIGNETTE

An established patient with a new lung mass and probable lung cancer presents with a desire to initiate hospice services and forgo curative treatment attempts. The documentation is as follows:

Subjective: 92-year-old male presents for follow-up of hemoptysis, fatigue, and weight loss, along with review of his recent chest CT. He reports moderate mid-back pain, new since last week. Appetite is fair. He denies fever. He continues to have occasional cough with mixed blood in the produced sputum.

Objective: BP 135/80, P 95, Weight down 5 pounds from 2 weeks ago, BMI 18.5, O2 sat 94% on RA.

General: Frail-appearing elderly male. No distress or shortness of breath. Able to speak in full sentences.

HEENT: No palpable lymph nodes.

Lungs: Frequent coughing and diffuse coarse breath sounds.

Heart: Regular rate and rhythm.

Ext: No extremity swelling.

MSK: Moderate tenderness over multiple thoracic vertebrae.

CT shows large right-sided lung mass suspicious for malignancy, along with a moderate left-sided effusion. Lytic lesions seen in T6-8.

Assessment: Lung mass, suspect malignancy with bone metastasis.

Plan: After extensive review of the findings, the patient was informed of the likely poor prognosis of the suspected lung cancer. We reviewed his living will, and he reiterated that he did not desire life-prolonging measures and would prefer to allow the disease to run its natural course. He also declines additional testing for diagnosis/prognosis. A shared decision was made to initiate hospice services. Specifically, we discussed need for oxygen and pain control. He declines pain medications for now, but will let us know. He and his son who was accompanying him voiced agreement and understanding of the plan.

CPT code: 99215

Explanation: Under the 2021 guidelines, high level MDM involves at least two of the following:

High number and complexity of problems addressed at the encounter,

Extensive amount and/or complexity of data to be reviewed and analyzed,

High risk of morbidity from additional diagnostic testing or treatment.

In this vignette, the patient has one acute or chronic illness or injury (suspected lung cancer) that poses a threat to life or bodily function. This is an example of a high complexity problem in the 2021 MDM guidelines. The physician reviewed one test (CT), so the amount and/or complexity of data is minimal. A decision not to resuscitate, or to de-escalate care, because of poor prognosis is an example of high risk of morbidity, and the physician has clearly documented that in the plan portion of the note. Consequently, even though the amount and/or complexity of data is minimal, the overall MDM remains high because of the problem addressed and the risk involved.

Under the new guidelines, total time means all time (face-to-face and non-face-to-face) the physician or other QHP personally spends on the visit on the date of service. Examples include time spent reviewing labs or reports, obtaining or reviewing history, ordering tests and medications, and documenting clinical information in the EHR.

The AMA has also created a new add-on code, 99417, for prolonged services. It can be used when the total time exceeds that of a level 5 visit – 99205 or 99215. (See “ Total time plus prolonged services template .”)

TIME-BASED CODING VIGNETTE

An established patient presents with a three-month history of fatigue, weight loss, and intermittent fever, and new diffuse adenopathy and splenomegaly. The documentation is as follows:

Subjective: 30-year-old healthy male with no significant PMH presents with a three-month history of fatigue, weight loss, and intermittent fever. He travels for work and has been evaluated in several urgent care centers and reassured that he likely had a viral syndrome. Fevers have been as high as 101, but usually around 100.5, typically in the afternoons. Testing for flu and acute mono has been negative. He denies high-risk sexual behavior and IV drug use. He denies any sick contacts. He has not had vomiting or diarrhea. He has not had any pain. He denies cough.

Objective: BP 125/80, P 92, BMI 27.4.

General: Well-nourished male, no distress.

HEENT: No abnormal findings.

Lungs: Clear.

Heart: No murmurs. Regular rate and rhythm.

Abdomen: Soft, non-tender, moderate splenomegaly.

Skin: Multiple petechia noted.

Lymph: Multiple cervical, axillary, and inguinal lymph nodes that are enlarged, mobile, and non-tender.

Assessment: Weight loss, lymphadenopathy, and splenomegaly

Plan: Prior to the visit, I spent 15 minutes reviewing the medical records related to his recent symptoms and various urgent care visits. We reviewed the differential at length to include infectious disease and acute myelodysplastic condition. I have ordered stat blood cultures, TB test, EBV titers, echo, and CBC. The pathologist called to report concerning findings on the CBC for likely acute leukemia. I called the patient to inform him of his results and need for additional testing. I also discussed the patient with oncology and arranged a follow-up visit for tomorrow. I spent a total of 92 minutes with record review, exam, and communication with the patient, communication with other providers, and documentation of this encounter.

CPT Codes: 99215 and 99417 x 3.

Explanation: In this instance, the physician has chosen to code based on time rather than MDM. The physician has documented 92 minutes associated with the visit on the date of service, including time not spent with the patient (e.g., time spent talking with the pathologist and time spent in documentation). According to the 2021 CPT code descriptors, 40–54 minutes of total time spent on the date of the encounter represents a 99215 for an established patient.

The 2021 CPT code set also notes that for services of 55 minutes or longer, you should use the prolonged services code, 99417, which can be reported for each 15 minutes beyond the minimum total time of the primary service (99215). The difference between the 92 minutes spent by the physician and the 40-minute minimum for 99215 is 52 minutes. There are three full 15-minute units of 99417 in those 52 minutes, so the physician may report three units of 99417 in addition to 99215. CPT 2021 instructs you to not report 99417 for any time unit less than 15 minutes, so the seven remaining minutes of prolonged service is unreportable.

Note that if this had been a new patient, the physician would only be able to report two units of 99417 in addition to 99205. Though the elements of MDM do not differ between new and established patients, the total time thresholds do. The range for a level 5 new patient is 60–74 minutes.

FINAL THOUGHTS

CPT does not dictate how physicians document their patient encounters. As illustrated above, a standard SOAP note can be used to support levels of MDM (and thus levels of service) under the 2021 guidelines.

Physicians who want to further solidify their documentation in case of an audit may choose to make the elements of MDM more explicit in their documentation. This could be particularly helpful for documenting the level of risk, which is the least clearly defined part of the MDM table and potentially most problematic because of its inherent subjectivity. Stating the level of risk and giving a rationale when possible allows a physician to articulate in the note the qualifying criteria for the submitted code. For example, going back to our vignette of moderate MDM, the physician could note in the chart, “This condition poses a threat to bodily function if not addressed, due to acute kidney injury for an obstructive stone.”

It is also worth noting that much of the note in each case is for purposes other than documenting the level of service. For instance, with history and physical exam no longer required, the subjective and objective portions of the note are recorded primarily for continuity or quality of care rather than to justify the level of service. This provides some administrative simplification. What's in the note will become more about what is needed for medical care and less about payment justification under the new guidelines. That's a plus for primary care.

We hope these examples are helpful as you prepare to implement the 2021 CPT changes. You can also visit https://www.aafp.org/emcoding for more resources and information.

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What are some commonly used CPT codes in Physical Therapy?

Physical Therapy (PT) is a growing field in healthcare. It helps individuals manage pain, recover from surgery or injury, and improve mobility through physical exercise. One of PT’s most important aspects is using Current Procedural Terminology (CPT) codes to bill for services provided accurately.

Knowing which CPT codes are commonly used in physical therapy can help streamline billing processes and ensure accuracy when submitting claims. 

Physical therapists face certain challenges when deciding which CPT codes to use. Because the codes vary depending on the type of treatment provided, it can be difficult to know which code best applies to each service.  

Fortunately, there are some common CPT codes used in physical therapy that can serve as a guide and help simplify the billing process. Before delving deeper into CPT codes, it’s essential to distinguish between CPT and ICD-10 codes, as they serve distinct purposes in medical coding.

Difference Between ICD-10 and CPT Codes:

The International Classification of Diseases (ICD-10) codes are used for medical diagnosis, whereas Current Procedural Terminology (CPT) codes are used for billing healthcare services – such as physical therapy. ICD-10 codes provide a standard language to describe the disease or condition being treated, while CPT codes are used to identify the services provided by the physical therapist.  

Understanding the differences between these codes and their respective uses is essential in ensuring accurate billing and reimbursement for services rendered.

An example of ICD-10 and  CPT codes used in physical therapy is as follows: 

A patient seeks physical therapy for a shoulder injury with the ICD-10 code of M75.22 (shoulder bursitis). The PT evaluates and treats the condition using the CPT codes 97161 (evaluation) and 97110 (therapeutic exercise).  

• Common CPT Codes in Physical Therapy

Physical therapy employs a variety of techniques and treatments, so the list of CPT codes used in physical therapy can be quite extensive. However, there are some codes that are more commonly used than others.  

The following three categories  are some of the most common CPT codes used in physical therapy: 

• Codes for initial Evaluations
• Code for re-evaluations
• Codes for Treatment

Codes for initial Evaluations:

• 97161: Physical therapy evaluation, low complexity.
• 97162: Physical therapy evaluation, moderate complexity.
• 97163: Physical therapy evaluation, high complexity.

Codes for Re-evaluations:

Re-evaluations are essential for assessing a patient’s progress and modifying treatment plans.

The common re-evaluation CPT code is:

• 97164: Re-evaluation of physical therapy established plan of care.

This code captures the time and effort spent on reviewing the patient’s response to treatment and making necessary adjustments.

Codes for Treatment:

• 97110: Therapeutic exercises. ((e.g. Structured movement, coordination).
• 97140: Manual therapy techniques (e.g., improve mobility,  enhance function).
• 97530: Therapeutic activities (e.g., gait training, balance exercises).
• 97535: Self-care/home management training (e.g., activities of daily living).
• Procedure Codes in Physical Therapy

(a) Timed-based Physical Therapy Procedure Codes:

Timed-based procedure codes are used when the therapy services are provided for a specific duration. The therapist’s time spent on a particular service determines the billing and reimbursement. 

Here are the timed-based physical therapy procedure codes:

Therapeutic Exercises (97110):

• Therapeutic exercises focus on improving strength, flexibility, and range of motion. This code encompasses activities such as stretching, strengthening exercises, and neuromuscular re-education.

Neuromuscular Re-education (97112):

• This code covers interventions designed to restore or enhance function by addressing impairments of the neuromuscular system. Techniques include proprioceptive training, balance exercises, and coordination activities.

Manual Therapy (97140):

• Manual therapy involves skilled hands-on techniques to mobilize or manipulate joints and soft tissues.

Therapeutic Activities (97530):

• Therapeutic activities involve dynamic, purposeful tasks to improve functional abilities. Examples include wheelchair mobility training, dynamic balance training, and aquatic therapy.

(b) Untimed Physical Therapy Procedure Code:

Untimed procedure codes are used when therapy services are not billed based on time but rather based on the completion of specific procedures or services.

Here are the untimed physical therapy procedure codes:

Evaluation (97161-97168):

Evaluation codes are used for the initial assessment of a patient’s condition and the formulation of an individualized treatment plan.

Orthotic and Prosthetic Management (97760-97762):

Orthotic and prosthetic management involves the fitting, adjustment, and monitoring of braces, splints, or prosthetic devices. This code includes the evaluation, fitting, and training associated with the use of these devices.

Gait Training (97116):

Gait training focuses on improving a patient’s ability to walk.It includes activities such as balance exercises, weight shifting, and the use of assistive devices like crutches or walkers.

• Modifier Codes

Modifier codes are an important part of physical therapy billing. They provide additional information about the service provided and can be used to describe services in more detail. Modifiers can also help distinguish between similar services performed on different dates or by different providers. 

Modifier 59  and Modifier XU are two of the most commonly used modifiers in physical therapy. Modifier 59 is used to indicate a distinct service from other services being performed on the same day, while Modifier XU is used when no other procedure code accurately describes the service provided. 

Providers use Modifier 59  to indicate that a distinct service has been provided on the same day as another service. This is especially helpful when describing services that are typically bundled together, such as evaluation and treatment services. 

Modifiers XE , XP , and XS  are used when there is no other procedure code that accurately describes the service provided. These modifiers indicate teaching, training, or supervision services that are not included in any other procedure codes and must be billed separately. 

Finally, Modifier KX can be used in physical therapy to indicate that all necessary components of the service were provided. This modifier helps providers differentiate between services that have been partially completed and those that are fully completed.

• Documentation Guidelines for CPT Coding in Physical Therapy

Accurate documentation is essential for proper billing of services provided by physical therapists. This includes providing detailed information on the patient’s diagnosis, the treatments and interventions used, and the results achieved. 

When documenting physical therapy services, it is important to ensure that all relevant information is included to help guide the selection of an appropriate CPT code. It  includes the patient’s diagnosis, treatment plan, type and duration of services provided (including any special instructions), as well as any progress notes or outcomes.

It is also important to be aware of the documentation guidelines set forth by individual insurance companies. These guidelines may differ from company to company, so it is important to familiarize yourself with the specific requirements for any payers you are working with.

• Final thoughts

Physical therapy is an important part of healthcare and CPT codes for PT are a key component to accurately billing for services rendered. Knowing which CPT codes are commonly used in physical therapy, including procedure codes, modifier codes, and time-based codes can help streamline the billing process.

With this knowledge, physical therapists can ensure accurate record-keeping and reimbursement when submitting claims. By understanding how ICD-10 and CPT codes differ from each other, providers will be better equipped to select the right code for their patient’s condition or service provided.

To enhance your billing efficiency, consider partnering with professional billing services. Their expertise and knowledge will help you navigate the complexities of billing, maximizing revenue and allowing you to focus on providing exceptional care to your patients.

• Difference Between ICD-10 and CPT Codes
• Codes for Re-evaluations
• Timed-based Physical Therapy Procedure Codes
• Untimed Physical Therapy Procedure Code

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The Ultimate Guide to Physical Therapy CPT Codes

Understanding Physical Therapy CPT Codes can seem like deciphering an intricate puzzle. With their unique combinations of numbers and letters, they play a critical role in the physical therapy (PT) landscape, particularly in billing and documentation. In this comprehensive guide, we'll unravel the complexities of these codes, helping you become well-versed in their usage, significance, and intricacies.

What are CPT Codes?

Current Procedural Terminology (CPT) codes serve as a universal language in the healthcare industry. Created and maintained by the American Medical Association, these codes are used to classify various medical, surgical, and diagnostic services and procedures. In the world of PT, CPT codes provide a standardized method of documenting and billing for services rendered during patient care.

The Most Common Physical Therapy CPT Codes

While there are hundreds of CPT codes, only a select few are frequently used in the realm of physical therapy. These codes, which range from evaluations to specific therapeutic procedures, are essential for PTs to accurately document patient care and receive appropriate reimbursement.

Evaluation Codes

Physical therapy begins with an evaluation, which sets the stage for the treatment plan. The complexity of the evaluation determines which of the following codes is used:

97161: Physical therapy evaluation, low complexity

97162: Physical therapy evaluation, moderate complexity

97163: Physical therapy evaluation, high complexity

97164: Physical therapy re-evaluation

When should I bill for an evaluation vs. a re-evaluation?

A common question among PTs is when to bill for an evaluation versus a re-evaluation. An evaluation is typically billed at the onset of care or when a new diagnosis is identified. A re-evaluation, on the other hand, is billed when there's a significant improvement, decline, or change in the patient's condition or treatment plan.

Should I bill for a re-evaluation each time I complete a progress note?

No. While progress notes are important for tracking a patient's progress, billing for a re-evaluation should only be done when there's a substantial change in the patient's status or treatment plan.

Treatment Codes

Following the evaluation, the PT will perform a variety of services or treatments, each with its corresponding CPT code. Here are some of the most commonly used codes:

97110: Therapeutic Exercise

CPT Code 97110 is any type of exercise that develops strength and endurance in one or more areas. The exercises also help with range of motion and flexibility. They get billed in 15-minute increments following the 8-minute rule. A physical therapist cannot bill for this physical therapy cpt code until the service lasts for at least 8 minutes. They can only bill for a single unit unless they provide the service through 22 minutes.

This cpt code for physical therapy requires direct contact time with the patient. This code often gets confused with therapeutic activity, but there is a significant difference between the two on the billing side. Therapeutic activity receives a higher average reimbursement rate from insurance companies compared to therapeutic exercise. The reimbursement difference is due to skill. Therapeutic exercise usually requires less skill compared to therapeutic activities or neuromuscular re-education. Insurance companies view therapeutic exercise as requiring less effort and skill, so it deserves less compensation.

97112: Neuromuscular Re-Education

Neuromuscular re-education involves exercises aimed at restoring function by retraining the brain in muscle control. These activities essentially facilitate communication between the brain and muscles, guiding them on how to function and move effectively. Billing for these activities is typically done in 15-minute units, following the 8-minute rule. The primary goal of neuromuscular re-education is to enhance posture, movement, balance, coordination, and kinesthetic sense, and it also encompasses proprioception for both sitting and standing activities.

Time spent on the following also counts as relevant activities for this code…

Kinesiotaping

Performing stabilization exercises

Ergonomic training

Facilitation or inhibition

Desensitizing the muscles

Improving motor control

Plyometrics

97116: Gait Training

Gait training encompasses a series of exercises specifically crafted to assist a patient in standing and walking. The primary objective is to fortify the muscles and joints in the individual's legs, enhance their balance and posture, and bolster their stamina. Additionally, the aim is to refine muscle memory and recondition leg movements through repetitive actions.Common reasons people need gait training include…

Broken pelvis

Joint replacement

Neurological disorders

Musculoskeletal disorders

Spinal cord injuries

These types of exercises often use machines that specifically help the person walk safely. The machines help support body weight, provide stability, and other forms of assistance while someone learns to develop strength and balance. Physical therapists also have their patients use strength-building machines, ellipticals, and treadmills to target this kind of training. They may also use a harness to help with balance while the patient relearns movements of walking. Walking over objects, lifting legs, sitting down/getting back up, or other activities can all help train the muscles to increase mobility.

97140: Manual Therapy

Manual therapy is described as "hands-on mobilization involving direct interaction with the patient, carried out by a licensed physical therapist (PT) or supervised assistant." The primary goal is to improve joint and soft tissue mobility, decrease joint contracture, and enhance muscle energy. Therapists achieve this by administering resistance and pressure. Consequently, the scope encompasses activities categorized as "manual resistance exercise," aimed at enhancing muscle strength and endurance to boost overall muscle energy.

97150: Group Therapy

The term "group" pertains to providing therapy to two or more patients concurrently, excluding individual sessions. The patients may or may not engage in the same exercises simultaneously. These sessions can take place in diverse environments, such as a gym or a pool. Due to the involvement of multiple patients, this form of treatment necessitates continuous supervision from the physical therapist or their assistant.

97530: Therapeutic Activities

The code provided in this section includes services that involve direct contact with the patient. These activities aim to enhance the functional performance of muscles, ligaments, and other body tissues. The exercises are referred to as "dynamic" because they require the patient to practice movements that involve strength, balance, and flexibility. The repetitive nature of these movements aids in muscle memory, ensuring that patients can safely perform the exercises outside of therapy.

These training exercises necessitate the expertise of a highly skilled physical therapist. The therapist must be capable of correcting and guiding the patient's movements to prevent injuries and help them master the proper techniques.

97016: Vasopneumatic Devices

Vasopneumatic devices are a type of therapeutic equipment used in physical therapy. These devices apply pressure to the limbs, helping to improve circulation and reduce swelling. They are commonly used in the treatment of conditions such as lymphedema and venous insufficiency. The pressure can be adjusted based on the patient's needs, and the therapy can be administered in conjunction with other treatments to maximize the benefits.

97032: Electrical Stimulation

Electrical stimulation is a widely used modality in physical therapy. It involves the application of electrical currents to stimulate nerves and muscles, promoting pain relief, muscle contraction, and tissue healing. This non-invasive technique can be used to treat various conditions, such as muscle weakness, nerve damage, and chronic pain. The intensity and frequency of the electrical currents can be adjusted based on the patient's needs and response to treatment.

Timed vs. Untimed Codes

In the world of PT billing, codes can be classified as timed or untimed. Timed codes correspond to services that are billed based on the amount of time spent with the patient, typically in 15-minute increments. Untimed codes, on the other hand, denote services that can be billed only once per session, regardless of the length of time spent on the service.

Physical Therapy Modifiers

Modifiers play an essential role in PT CPT coding. They provide additional information about the service or procedure performed, allowing for more accurate billing. For example, Modifier 59 indicates that a service or procedure was distinct or separate from other services performed during the same session.

Modifier 59

Modifier 59 signifies that a distinct service or procedure was performed separately from another non-evaluation and management service. It's vital in ensuring that both services comply with the National Correct Coding Initiative.

GP Modifier

The GP modifier is used to indicate that a PT's services were provided, often used in inpatient and outpatient multidisciplinary settings.

KX Modifier

The KX modifier is used when services provided to a patient exceed Medicare’s $2,010 threshold. This modifier ensures that continued treatment is justified with appropriate documentation in the patient's medical record.

XE Modifier

Modifier XE indicates a service was distinct because it occurred during a separate encounter.

XP Modifier

This modifier indicates a service was distinct because it was performed by a different practitioner.

Remote Therapeutic Monitoring (RTM) codes are a new addition to the PT CPT coding landscape. These codes enable PTs to bill for remote patient monitoring services, reflecting the evolving nature of patient care in the digital age.

98975 - Initial Setup and Patient Education

Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment. Billing Frequency: Billed once at the start of an episode

98976 - Monthly Data Transmission and Supply of Device for Monitoring– Respiratory System

Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days. Billing Frequency: Can be billed once every 30 days

98977 - Monthly Data Transmission and Supply of Device for Monitoring— Musculoskeletal System

Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days. Billing Frequency: Can be billed once every 30 days

98980 - Monitoring/Treatment Management Services, First 20 Minutes

Remote therapeutic monitoring treatment management services, physician/other qualified healthcare professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes. Billing Frequency: Can be billed every calendar month

Reimbursement for Physical Therapy CPT Codes

Based on the 2024 Medicare fee schedule for outpatient physical therapy services the following represents the 2024 Physical Therapy Reimbursement Rates .

Reimbursement for CPT Code 97110: Therapeutic Exercises

Therapeutic exercises $28.82 (2024)

Reimbursement for CPT Code 97112: Neuromuscular Reeducation

Neuromuscular reeducation $33.07 (2024)

Reimbursement for CPT Code 97140: Manual Therapy

Manual therapy $28.82 (2024)

Reimbursement for CPT Code 97530: Therapeutic Activities

Therapeutic activities $36.02 (2024)

Reimbursement for CPT Code 97116: Gait Training

Gait training $28.82 (2024)

Reimbursement for CPT Code 97150: Group Therapeutic Procedures

Group therapeutic $17.68 (2024)

Reimbursement for CPT Code 97161: PT Eval Low Complexity

PT eval low complex $98.56 (2024)

Reimbursement for CPT Code 971612: PT Eval Moderate Complexity

PT eval moderate complex $98.56 (2024)

Reimbursement for CPT Code 97163: PT Eval High Complexity

PT eval high complex $98.56 (2024)

Reimbursement for CPT Code 97164: PT Re-eval Establish Plan of Care

PT re-eval $68.44 (2024)

Mastering Physical Therapy CPT Codes is crucial for PTs to ensure accurate documentation and appropriate reimbursement. While it may seem daunting at first, a solid understanding of these codes can streamline the billing process, improve communication with insurance providers, and ultimately lead to more efficient and effective patient care. Remember, the key to successful PT billing lies in the details – accurate coding, thorough documentation, and consistent tracking of services rendered.

Related Posts

The Physical Therapy Billing Guide: A Checklist to a Healthy Revenue Cycle

2024 Physical Therapy Reimbursement Rates

Credit Card Processing for Physical Therapy Practices

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Billing and Coding: Outpatient Physical and Occupational Therapy Services

Document note, note history, contractor information, article information, general information.

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023 , the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

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. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Title XVIII of the Social Security Act (SSA): Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Sections 1861(g), 1861(p), 1861(s)(2) and 1862(a)(14) of Title XVIII of the Social Security Act define the services of non-physician practitioners. Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Section 1862(a)(20) excludes payment for PT or OT services furnished incident to the physician by personnel that do not meet the qualifications that apply to therapists, except licensing. Code of Federal Regulations 42 CFR, Sections 410.59 and 410.61 describe outpatient occupational therapy services and the plan of treatment for outpatient rehabilitation services, respectively. 42 CFR, Sections 410.60 and 410.61 describe outpatient physical therapy services and the plan of treatment for outpatient rehabilitation services, respectively. 42 CFR, Sections 410.74, 410.75, 410.76, and 419.22 define the services of non-physician practitioners. 42 CFR, Sections 424.24 and 424.27 describe therapy certification and plan requirements. 42 CFR, Sections 424.4, 482.56, 484 and 485.705 define therapy personnel qualification requirements. 42 CFR, Section 486 describes coverage for services rendered by physical therapists in independent practice. Federal Register Federal Register, Vol. 72, No. 227, November 27, 2007, pages 66328-66333 and 66397-66408, and the correction notice for this rule, published in the Federal Register on January 15, 2008, pages 2431-2433, addresses personnel qualification standards for therapy services and certification requirements. Federal Register, July 22, 2002, Decision Memo for Neuromuscular Electrical Stimulation (NMES) for Spinal Cord Injury (CAG 00153R), at: http://www.cms.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=55& CMS Publications: CMS Publication 100-02, Medicare Benefit Policy Manual , Chapter 15:

CMS Publication 100-03, Medicare National Coverage Decisions (NCD) Manual , (multiple sections):

CMS Publication 100-04, Claims Processing Manual , Chapter 5:

CMS Publication 100-04, Claims Processing Manual , Chapter 20:

CMS, “11 Part B Billing Scenarios for PTs and OTs”, http://www.cms.hhs.gov/TherapyServices/02_billing_scenarios.asp#TopOfPage Communication from CMS that the Contractor LCD is not required to include the V57.1-V57.89 ICD-9-CM codes.

CMS Transmittal No. 4149, Publication 100-04, Medicare Claims Processing Manual , October 23, 2018, removes Functional Reporting requirements and edits for outpatient therapy services.

CMS Transmittal No. 179, Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius, Change request #8458, January 14, 2014, provides clarification that coverage of skilled nursing and skilled therapy services “…does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.”

Article Guidance

This article contains coding guidelines that complement the Local Coverage Determination (LCD) for Outpatient Physical and Occupational Therapy Services (L33631).

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

Unless otherwise specified, italicized text within this article represents quotation from CMS sources.

CMS National Coverage provisions:

Services that do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services. For example, services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation, do not constitute (covered) therapy services for Medicare purposes.

MAINTENANCE PROGRAM (MP) means a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness.

In the case of rehabilitative therapy, i mprovement is evidenced by successive objective measurements whenever possible. If an individual’s expected rehabilitation potential is insignificant in relation to the extent and duration of therapy services required to achieve such potential, rehabilitative therapy is not reasonable and necessary.

Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and easily reversible loss or reduction in function which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities (CMS Publication 100-02, Medicare Benefit Policy Manual, chapter 15, section 220.2(C)).

In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.

Skilled Therapy A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist. If a service can be self-administered or safely and effectively furnished by an unskilled person, without the direct or general supervision, as applicable, of a therapist, the service cannot be regarded as a skilled therapy service even though a therapist actually furnishes the service. Similarly, the unavailability of a competent person to provide a non-skilled service, notwithstanding the importance of the service to the patient, does not make it a skilled service when a therapist furnishes the service.

Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.

Rehabilitative therapy occurs when the skills of a therapist (as defined by the scope of practice for therapists in each state) are necessary to safely and effectively furnish a recognized therapy service, whose goal is improvement of an impairment or functional limitation.

Once a maintenance program is established, coverage of therapy services to carry out a maintenance program turns on the beneficiary’s need for skilled care. A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel. In such situations, coverage is not provided. However, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program.

While a beneficiary’s particular medical condition is a valid factor in deciding if skilled (rehabilitative or maintenance)therapy services are needed, a beneficiary’s diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a qualified therapist are needed to treat the illness or injury, or whether the service(s) can be carried out by non-skilled personnel

Therapy Students

Qualified professionals may serve as clinical instructors for therapy students within their scope of practice. Physical therapist assistants and occupational therapy assistants may only serve as clinical instructors for physical therapist assistant students and occupational therapy assistant students, respectively, when performed under the direction and supervision of the licensed physical or occupational therapist (in states where licensure applies). Services performed by a student (therapy student or therapy assistant student) are not reimbursed, even if provided under “line of sight” supervision of the therapist. However, the services of a qualified professional are covered, even when a student is participating in the care. To be covered when the student is participating, the qualified professional must be present in the room and must:

• direct the service, making the skilled judgment and assessment, and assume responsibility for the treatment;
• not be engaged in treating another patient or doing other tasks at the same time (such as documentation); AND must
• sign all documentation appropriately. A student may also sign the documentation, but it is not necessary since the Part B payment is for the qualified professional’s service, not for the student’s services.

Supervision Levels

Supervision levels for outpatient therapy services depend on the setting where they are provided. Direct supervision (in the office suite) by a physician/NPP is required for therapists and qualified auxiliary personnel when therapy services are provided incident to the services of a physician/NPP. Also, direct supervision by a physical therapist (for PTAs) or occupational therapist (for OTAs) is required when assistants provide therapy services in the private practice setting or in the office of a physician/NPP. General supervision (the supervising therapist is available but not necessarily on the premises) is required by a physical therapist (for PTAs) or occupational therapist (for OTAs) when therapy services are provided in any other setting.

Private Practice Therapy Services

To qualify as a private practice, each individual must be enrolled as a private practitioner and employed in one of the following practice types:

• unincorporated solo practice, partnership, or group practice;
• physician/NPP group or groups that are not professional corporations, if allowed by state and local law;
• physical or occupational therapist employed by physician/NPP group practices (PTPP, OTPP), if state and local law permits this employee relationship.

Private practice also includes therapists who are practicing therapy as employees of another supplier, of a professional corporation or other incorporated therapy practice. Private practice does not include individuals when they are working as employees of an institutional provider.

Services should be furnished in the therapist’s or group’s office or in the patient’s home. The office is defined as the location(s) where the practice is operated during the hours that the therapist engages in the practice at that location. If the services are furnished in a private practice office space, that space shall be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice.

Therapy Provided by Physicians and Physician Employees

The services of PTAs and OTAs also may not be billed incident to a physician’s/NPP’s service. However, if a PT and PTA (or an OT and OTA) are both employed in a physician’s office, the services of the PTA, when directly supervised by the PT or the services of the OTA, when directly supervised by the OT may be billed by the physician group as PT or OT services using the PIN/NPI of the enrolled PT (or OT). (See Section 230.4 for private practice rules on billing services performed in a physician’s office.) If the PT or OT is not enrolled, Medicare shall not pay for the services of a PTA or OTA billed incident to the physician’s service, because they do not meet the qualification standards in 42CFR484.4.

Coding Information and Documentation Requirements for Specific Services:

CPT 97161-97163 – Physical therapy evaluation CPT 97165-97167 – Occupational therapy evaluation

When an evaluation is the only service provided by a provider/supplier in an episode of treatment, the evaluation serves as the plan of care if it contains a diagnosis, or in states where a therapist may not diagnose, a description of the condition from which a diagnosis may be determined by the referring physician/NPP. The goal, frequency, and duration of treatment are implied in the diagnosis and one-time service. The referral/order of a physician/NPP is the certification that the evaluation is needed and the patient is under the care of a physician. Therefore, when evaluation is the only service, a referral/order and evaluation are the only required documentation. If the patient presented for evaluation without a referral or order and does not require treatment, a physician referral/order or certification of the evaluation is required for payment of the evaluation. A referral/order dated after the evaluation shall be interpreted as certification of the plan to evaluate the patient.

For initial evaluations, PTs shall use codes 97161-97163 and OTs shall use codes 97165-97167. Physicians and other qualified non-physician providers should use the evaluation and management codes 99201-99350 for evaluations.

Consider the following points when billing for an evaluation.

• Do not bill for a therapy initial evaluation for each therapy discipline on more than one date of service. If an evaluation spans more than one day, the evaluation should only be billed as one unit for the entire evaluation service (typically billed on the day that the evaluation is completed). Do not count as therapy “treatment” the additional minutes needed to complete the evaluation during the subsequent session(s).
• Do not bill test and measurement, range of motion (ROM) or manual muscle testing (MMT) codes (CPT 95851-95852, 97750, 97755) on the same day as the initial evaluation. The procedures performed are included in the initial evaluation codes and are not allowed by the Correct Coding Initiative(CCI) edits.
• CPT codes 95831-95834 are deleted for 2020. To report manual muscle testing, please refer to evaluation codes 97161-97168.
• Do not bill therapy screenings utilizing the evaluation codes. Screenings are not billable services.
• If treatment is given on the same day as the initial evaluation, the treatment is billed using the appropriate CPT codes. The documentation must clearly describe the treatment that was provided in addition to the evaluation.

CPT 97164 – Physical therapy reevaluation CPT 97168 – Occupational therapy reevaluation The reevaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment, or terminating services . Continuous assessment of the patient’s progress is a component of the ongoing therapy services, and is not payable as a reevaluation.

Consider the following points when billing for a reevaluation.

• Indications for a reevaluation include new clinical findings, a significant change in the patient's condition, or failure to respond to the therapeutic interventions outlined in the plan of care.
• When reevaluations are done for a significant change in condition, documentation must show a significant improvement, decline or change in the patient’s diagnosis, condition or functional status that was not anticipated in the current plan of care. When a patient exhibits a demonstrable change in functional ability, a reevaluation may be necessary to revise long term goals and interventions. The plan of care may need to be revised and recertified if significant changes are made, such as a change in the long-term goals.
• Therapy reevaluations should contain all the applicable components of an initial evaluation and must be completed by a clinician. (See the Reevaluation section of Documentation Requirements for information regarding therapy assistant participation in the reevaluation process.)
• A reevaluation is not a routine, recurring service. Do not bill for routine reevaluations, including those done for the purpose of completing an updated plan of care, a recertification report, a progress report, or a physician progress report . Although some state regulations and practice acts require reevaluations at specific intervals, for Medicare payment, reevaluations must meet Medicare coverage guidelines.
• These reevaluation codes are untimed, billable as one unit.
• Do not bill for reevaluations as unlisted codes (97039, 97139, 97799) or test and measurement, ROM, MMT codes (95831-95834, 95851-95852, 97750, 97755).

Supportive Documentation Requirements for 97161-97163, 97164, and 97165-97167, 97168 Refer to the Documentation Requirements Section of this Article  for further information.

General Modality Guidelines (CPT codes 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, G0281, G0283, and G0329)

Based on the CPT descriptors, these modalities apply to one or more areas treated (e.g., paraffin bath used for the left and right hand is billed as one unit).

CPT codes 97012, 97016, 97018, 97022, 97024, 97026, and 97028 require supervision by the qualified professional/auxiliary personnel of the patient during the intervention.

CPT codes 97032, 97033, 97034, 97035, 97036, and 97039 require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes indicates the provider is performing the modality and cannot be performing another procedure at the same time. Only the actual time of the provider’s direct contact with the patient, providing services requiring the skills of a therapist, is covered for these codes.

Code 97010 is bundled. It may be bundled with any therapy code. Regardless of whether code 97010 is billed alone or in conjunction with another therapy code, this code is never paid separately. If billed alone, this code will be denied.

Supportive Documentation Requirements for 97010

• The area(s) treated
• The type of hot or cold application

CPT 97012 - Traction, Mechanical (to one or more areas) Documentation should support the medical necessity of continued traction treatment in the clinic for greater than 12 visits. For cervical conditions, treatment beyond one month can usually be accomplished by self-administered mechanical traction in the home. The time devoted to patient education related to the use of home traction should be billed under 97012. Only 1 unit of CPT code 97012 is generally covered per date of service.

Non-Surgical Spinal Decompression Non-surgical spinal decompression is performed for symptomatic relief of pain associated with lumbar disk problems. The treatment combines pelvic and/or cervical traction connected to a special table that permits the traction application. There is insufficient scientific data to support the benefits of this technique. Therefore, non-surgical spinal decompression is not covered by Medicare (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual: Section 160.16).

Examples of this type of non-covered procedure include, but are not limited to, VAX-D™, DRX-3000, DRX9000, Decompression Reduction Stabilization (DRS) System, IDD, MedX., Spina System, Accua-Spina System, SpineMED Decompression Table, Lordex Traction Unit, Triton DTS, and Z-Grav.

If billed for purpose of receiving a denial, these services should be billed using CPT code 97039 and not with CPT 97012.

Supportive Documentation Requirements for 97012

Type of traction and part of the body to which it is applied, etiology of symptoms requiring treatment.

CPT 97014 – Electrical stimulation (unattended) (to one or more areas) CPT 97014 is not a Medicare recognized code. See HCPCS code G0283 for electrical stimulation (unattended).

CPT 97016 - Vasopneumatic Devices (to one or more areas)

See NCD 280.6 in CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual for further coverage and use information on Pneumatic Compression Devices.

Supportive Documentation Requirements for 97016

• Area of the body being treated, location of edema
• Objective edema measurements (1+, 2+ pitting, girth, etc.), comparison with uninvolved side
• Effects of edema on function
• Type of device used

CPT 97018 Paraffin Bath (to one or more areas)

Once a trial of monitored paraffin treatment has been done in the clinic over 1-2 visits and the patient has had a favorable response, the patient can usually be taught to use a paraffin unit in 1-2 visits. Consequently, it is inappropriate for a patient to continue paraffin treatment in the clinic setting.

Only 1 unit of CPT code 97018 is generally covered per date of service.

Supportive Documentation Requirements for 97018

• Documentation needs to support more than 2 visits to educate patient and/or caregiver in home use once effectiveness has been determined.
• Rationale for requiring the unique skills of a therapist to apply and train the patient/caregiver, including the complicating factors
• Area of body treated

CPT 97022 – Whirlpool (to one or more areas)

If greater than 8 visits are needed for whirlpools that require the skills of a therapist, the documentation should support the medical necessity of the continued treatment.

Whirlpool should not be separately billed when provided on the same date of service as debridement (97597-97598) for the same body part.

Fluidotherapy is a superficial dry heat modality consisting of a whirlpool of finely divided solid particles suspended in a heated air stream, the mixture having the properties of a liquid. Use of fluidized therapy dry heat is covered as an acceptable alternative to other heat therapy modalities in the treatment of acute or sub-acute traumatic or non-traumatic musculoskeletal disorders of the extremities. (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 150.8)

Supportive Documentation Requirements for 97022

• Rationale for requiring the unique skills of a therapist to apply, including the complicating factors
• Area(s) being treated

Only 1 unit of CPT code 97022 should be billed per date of service.

CPT 97024 – Diathermy (i.e., microwave)

Only 1 unit of CPT code 97024 is covered per date of service.

(CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual , Section 150.5) If no objective and/or subjective improvement is noted after 6 treatments, a change in treatment plan (alternative strategies) should be implemented, or documentation should include the therapist’s rationale for continued diathermy. Documentation must clearly support the need for diathermy more than 12 visits.

Supportive Documentation Requirements (required at least every 10 visits) for 97024

• Objective clinical findings/measurements to support the need for a deep heat treatment
• Subjective findings to include pain ratings, pain location, activities which increase or decrease pain, effect on function, etc.

CPT 97026 – Infrared (to one or more areas) - including Anodyne

Not covered: The Centers for Medicare & Medicaid Services has determined that there is sufficient evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and necessary. The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. See CMS Publication 100-03 Medicare National Coverage Determinations NCD) Manual, section 270.6 and Publication 100-04, Medicare Claims Processing Manual, Chapter 5, section 20.4 .

CPT 97028 - Ultraviolet (to one or more areas)

Only 1 unit of CPT code 97028 should be billed per date of service.

Supportive Documentation Requirements (required at least every 10 visits) for 97028

• Objective clinical findings/measurements to support the need for ultraviolet
• Minimal erythema dosage

CPT 97032 – electrical stimulation (manual) (to one or more areas), each 15 minutes

• See codes G0281-G0283 for instructions regarding supervised electrical stimulation.

97032 is a constant attendance electrical stimulation modality that requires direct (one-on-one) manual patient contact by the qualified professional/auxiliary personnel. Because the use of a constant, direct contact electrical stimulation modality is less frequent, documentation should clearly describe the type of electrical stimulation provided, as well as the medical necessity of the constant contact to justify billing 97032 versus G0283. Devices delivering high voltage stimulation may require one-on-one patient contact (e.g., MicroVas, when applied in a high voltage mode).

Types of electrical stimulation that may require constant attendance and should be billed as 97032 when continuous presence by the qualified professional/auxiliary personnel is required include the following examples.

• Direct motor point stimulation delivered via a probe
• Instructing a patient in the use of a home TENS unit
• Once a trial of TENS has been done in the clinic over 1-2 visits and the patient has had a favorable response, the patient can usually be taught to use a TENS unit for pain control in 1-2 visits. Consequently, it is inappropriate for a patient to continue treatment for pain with a TENS unit in the clinic setting
• Note that CPT code 64550 is for application of surface (transcutaneous) neurostimulator and is an operative/postoperative code. Use of this code would seldom fall under a therapy plan of treatment.
• Use for Walking in Patients with Spinal Cord Injury (SCI) The type of NMES that is used to enhance the ability to walk of SCI patients is commonly referred to as functional electrical stimulation (FES). See the section on CPT code 97116 for information on coverage for this use of NMES. (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual , section 160.12)

Most non-wound care electrical stimulation treatment provided in therapy should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment.

Functional Electrical Stimulation (FES) or Neuromuscular Electrical Stimulation (NMES) while performing a therapeutic exercise or functional activity may be billed as 97032. Do not bill for CPT codes 97110, 97112, 97116 or 97530 for the same time period.

Ultrasound with electrical stimulation provided concurrently (e.g., Medcosound, Rich-Mar devices), should be billed as ultrasound (97035). Do not bill for both ultrasound and electrical stimulation for the same time period.

If providing an electrical stimulation modality that is typically considered supervised (G0283) to a patient requiring constant attendance for safety reasons due to cognitive deficits, do not bill as 97032. This type of monitoring may be done by non-skilled personnel.

Non-Implantable Pelvic Floor Electrical Stimulation (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 230.8.) Non-implantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature

The methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (mA), pulse duration (duty cycle), treatments per day, number of treatment days per week, length of time for each treatment session, overall time period for device use, and between clinic and home settings. In general, the stimulus frequency and other parameters are chosen based on the patient's clinical diagnosis.

Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training.

A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.

The patient's medical record must indicate that the patient receiving a non-implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of pelvic muscle exercise (PME) training.

Stimulation delivered by vaginal or anal probes connected to an external pulse generator may be billed as 97032. Stimulation delivered via electrodes should be billed as G0283.

Documentation must clearly support the medical necessity of electrical stimulation more than 12 visits as adjunctive therapy or for muscle retraining.

Supportive Documentation Requirements (required at least every 10 visits) for 97032

• Type of electrical stimulation used (do not limit the description to “manual” or “attended”)
• If used for muscle weakness, objective rating of strength and functional deficits
• If used for pain include pain rating, location of pain, effect of pain on function

CPT 97033 – Iontophoresis (to one or more areas)

Iontophoresis is the introduction into the tissues, by means of an electric current, of the ions of a chosen medication.

Iontophoresis will be allowed for treatment of intractable, disabling primary focal hyperhidrosis (ICD-10-CM codes L74.510-L74.513 or L74.519) that has not been responsive to recognized standard therapy. Good hygiene measures, extra-strength antiperspirants (for axillary hyperhidrosis), and topical aluminum chloride should initially be tried.

CPT 97034 - Contrast Baths (to one or more areas)

Contrast baths are a form of therapeutic heat and cold applied to distal extremities in an alternating pattern. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold.

CPT Code 97034 is not covered when the services provided are hot and cold packs. This modality should be used in conjunction with therapeutic procedures, not as an isolated treatment.

This is a constant attendance code requiring direct, one-on-one patient contact by the provider. Only the actual time of the provider’s direct contact with the patient is to be billed.

Supportive Documentation Requirements (required at least every 10 visits) for 97034

• Rationale requiring the unique skills of a therapist to apply, including the complicating factors
• Subjective findings to include pain ratings, pain location, effect on function

Documentation must indicate the presence of these complicating factors for reimbursement of this code. If there are no complicating factors requiring the skills of a therapist, this modality is non-covered.

CPT 97035 – Ultrasound (to one or more areas)

See list of “ICD-10 Codes that DO NOT Support Medical Necessity”

Phonophoresis (the use of ultrasound to enhance the delivery of topically applied drugs) will be reimbursed as ultrasound, billable using CPT 97035. Separate payment will not be made for the contact medium or drugs.

Ultrasound with electrical stimulation provided concurrently (e.g., Medcosound, Rich-Mar devices), should be billed as ultrasound (97035). Do not bill for both ultrasound and electrical stimulation for the same time period.   Supportive Documentation Requirements (required at least every 10 visits) for 97035

• Frequency and intensity of ultrasound
• Objective clinical findings such as measurements of range of motion and functional limitations to support the need for ultrasound

If no objective and/or subjective improvement is noted after 6 treatments, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of ultrasound. Documentation must clearly support the need for ultrasound more than 12 visits.

C PT 97036 – Hubbard Tank (to one or more areas)

This modality involves the patient’s immersion in a tank of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers, or exfoliative skin conditions.

Hubbard tank treatments more than 12 visits require clear documentation supporting the medical necessity of continued use of this modality.

Supportive Documentation Requirements for 97036

CPT 97039 - Unlisted Modality (Specify type and time if constant attendance) If an existing CPT code does not describe the service performed, an unlisted CPT code may be used. The use of unlisted codes should be rare. If unlisted codes are billed, the claim and medical record must clearly state what modality or procedure is billed as an unlisted code. If not, the unlisted code billed will be subject to denial for insufficient information.

Note: Low level/cold laser light therapy (LLLT) is considered not reasonable and necessary under SSA 1862(a)(1)(A) and is not payable by Medicare. This procedure is considered non-covered billed under any HCPCS/CPT codes, including S8948 and 97039. Effective 7/1/2019, this service is reported with CPT code 0552T. Effective 1/1/2024, CPT 97037 (application of a modality to 1 or more areas; low-level laser therapy (ie, nonthermal and non-ablative) for post operative pain reduction.) has been added and is also non-covered by Medicare.

Supportive Documentation Requirements for 97039 Please see section Documentation Requirements for Unlisted Procedure Codes.

CPT G0283 - Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care

See 97032 for instructions in manual electrical stimulation.

Code G0283 is classified as a “supervised” modality, even though it is labeled as “unattended.” A supervised modality does not require direct (one-on-one) patient contact by the provider. Most electrical stimulation conducted via the application of electrodes is considered unattended electrical stimulation. Examples of unattended electrical stimulation modalities include Interferential Current (IFC), Transcutaneous Electrical Nerve Stimulation (TENS), cyclical muscle stimulation (Russian stimulation).

If unattended electrical stimulation is used for control of pain and swelling, there should be documented objective and/or subjective improvement in swelling and/or pain within 6 visits. If no improvement is noted, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality.

Documentation must clearly support the need for electrical stimulation more than 12 visits. Some patients can be trained in the use of a home TENS unit for pain control. Only 1-2 visits should be necessary to complete the training (which may be billed as 97032). Once training is completed, code G0283 should not be billed as a treatment modality in the clinic.

Non-Implantable Pelvic Floor Electrical Stimulation (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 230.8.) Non-implantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature . Stimulation delivered by vaginal or anal probes connected to an external pulse generator may be billed as 97032. Stimulation delivered via electrodes should be billed as G0283.

The methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (mA), pulse duration (duty cycle), treatments per day, number of treatments days per week, length of time for each treatment session, overall time period for device use, and between clinic and home settings. In general, the stimulus frequency and other parameters are chosen based on the patient's clinical diagnosis.

The patient's medical record must indicate that the patient receiving a non-implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of pelvic muscle exercise (PME) training. Documentation should also include the method of delivery (e.g., probe or electrode).

The charges for the electrodes are included in the practice expense portion of code G0283. Do not bill the Medicare contractor or the patient for electrodes used to provide electrical stimulation as a clinic modality. Do not bill Medicare for unattended electrical stimulation using code 97014.

Supportive Documentation Requirements (required at least every 10 visits) for G0283

• Type of electrical stimulation used (e.g., TENS, IFC)

THERAPEUTIC PROCEDURES

General Guidelines for Therapeutic Procedures (CPT codes 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140, 97150, 97530, 97533, 97535, 97537, 97542, 97602, 97605, 97606, 97607, 97608, 97750, 97755, 97760, 97761, 97763 and 97799)

Under Medicare, time spent in documentation of services (medical record production) is part of the coverage of the respective CPT code; there is no separate coverage for time spent on documentation (except for CPT Code 96125).

CPT codes 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97140, 97530, 97533, 97535, 97537, 97542, 97760, 97761, and 97763 describe different types of therapeutic interventions. The expected goals documented in the treatment plan, effected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any one or a combination of these procedures may be used in a treatment plan, documentation must support the use of each procedure as it relates to a specific therapeutic goal.

CPT 97110 - Therapeutic Exercises to develop strength and endurance, range of motion and flexibility (one or more areas, each 15 minutes)

For many patients a passive-only exercise program should not be used more than 2-4 visits to develop and train the patient or caregiver in performing PROM. Documentation would be necessary to support services beyond this level (such as PROM where these is an unhealed, unstable fracture, or new rotator cuff repair, requiring the skills of a therapist to ensure that the extremity is maintained in proper position and alignment during the PROM).

Documentation should include not only measurable indicators such as functional loss of joint motion or muscle strength, but also information on the impact of these limitations on the patient’s life and how improvement in one or more of these measures leads to improved function.

Documentation of progress should show the condition is responsive to the therapy chosen and that the response is (or is expected to be) clinically meaningful. Metrics of progress that are functionally meaningful (or obviously related to clinical functional improvement) should be documented wherever possible. For example, long courses of therapy resulting in small changes in range of motion might not represent meaningful clinical progress benefiting the patient’s function.

Documentation should describe new exercises added, or changes made to the exercise program to help justify that the services are skilled. Documentation must also show that exercises are being transitioned as clinically indicated to an independent or caregiver-assisted exercise program (“home exercise program” (HEP)). An HEP is an integral part of the therapy plan of care and should be modified as the patient progresses during the course of treatment. It is appropriate to transition portions of the treatment to an HEP as the patient or caregiver master the techniques involved in the performance of the exercise.

If an exercise is taught to a patient and performed for the purpose of restoring functional strength, range of motion, endurance training, and flexibility, CPT code (97110) is the appropriate code. For example, a gym ball exercise used for the purpose of increasing the patient’s strength should be considered as therapeutic exercise when coding for billing. Also, the minutes spent taping, such as McConnell taping, to facilitate a strengthening intervention would be counted under 97110.

Documentation must clearly support the need for continued therapeutic exercise greater than 12-18 visits.

Supportive Documentation Requirements (required at least every 10 visits) for 97110

• Objective measurements of loss of strength and range of motion (with comparison to the uninvolved side) and effect on function
• Specific exercises performed, purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills of a therapist were required
• When skilled cardiopulmonary monitoring is required, include documentation of pulse oximetry, heart rate, blood pressure, perceived exertion, etc.

CPT 97112 - Neuromuscular Re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (one or more areas, each 15 minutes)

This therapeutic procedure is provided for the purpose of restoring balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation (PNF), BAP’s boards, vestibular rehabilitation, desensitization techniques, balance and posture training).

If an exercise/activity is taught to the patient and performed for the purpose of restoring functional balance, motor coordination, kinesthetic sense, posture, or proprioception for sitting or standing activities, CPT (97112) is the appropriate code. For example, a gym ball exercise used for the purpose of improving balance should be considered as neuromuscular reeducation when coding for billing. The minutes spent taping, such as McConnell taping or kinesiotaping techniques, to enhance proprioception would be counted under CPT code 97112.

When therapy is instituted because there is a history of falls or a falls screening has identified a significant fall risk, documentation should indicate:

• specific fall dates and/or hospitalization(s) and reason for the fall(s), if known;
• most recent prior functional level of mobility, including assistive device, level of assist, frequency of falls or “near-falls”;
• cognitive status;
• prior therapy intervention;
• functional loss due to the recent change in condition;
• balance assessments (preferably standardized), lower extremity ROM and muscle strength testing;
• patient and caregiver training;
• carry-over of therapy techniques to objectively document progress. 

Documentation must clearly support the need for continued neuromuscular reeducation greater than 12-18 visits.

Supportive Documentation Requirements (required at least every 10 visits) for 97112

Objective loss of activities of daily living (ADLs), mobility, balance, coordination deficits, hypo- and hypertonicity, posture and effect on function. ADL means basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring.

Specific exercises/activities performed (including progression of the activity), purpose of the exercises as related to function, instruction given, and/or assistance needed, to support that the skills of a therapist were required.

CPT 97113 - Aquatic Therapy with Therapeutic Exercises (one or more areas, each 15 minutes)

Aquatic therapy refers to any therapeutic exercise, therapeutic activity, neuromuscular re-education, or gait activity that is performed in a water environment including whirlpools, hubbard tanks, underwater treadmills and pools.

See CPT 97150 Group Therapy for guidelines when treating more than one patient at the same time in the aquatic environment.

This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers).

Documentation must clearly support the need for aquatic therapy greater than 8 visits.

The aquatic therapy treatment minutes counted toward the total timed code treatment minutes should only include actual skilled exercise time that required direct one-on-one patient contact by the qualified professional/auxiliary personnel. Do not include minutes for the patient to dress/undress, get into and out of the pool, etc.

Do not bill for the water modality used to provide the aquatic environment, such as whirlpool (97022), in addition to 97113.

Supportive Documentation Requirements (required at least every 10 visits) for 97113

• Justification for use of a water environment
• Objective loss of ADLs, mobility, ROM, strength, balance, coordination, posture and effect on function
• Specific exercises/activities performed (including progression of the activity), purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills and of a therapist were required.

CPT 97116 - Gait Training (includes stair climbing) (one or more areas, each 15 minutes)

Documentation must clearly support the need for continued gait training beyond 12-18 visits within a 4-6 week period.

Neuromuscular Electrostimulation - Use for Walking in Patients with Spinal Cord Injury (SCI) (CPT code 97116) - The type of NMES that is used to enhance the ability to walk of SCI patients is commonly referred to as functional electrical stimulation (FES). These devices are surface units that use electrical impulses to activate paralyzed or weak muscles in precise sequence. Coverage for the use of NMES/FES is limited to SCI patients, for walking, who have completed a training program, which consists of at least 32 physical therapy sessions with the device over a period of 3 months. The trial period of physical therapy will enable the physician treating the patient for his or her spinal cord injury to properly evaluate the person's ability to use these devices frequently and for the long term. Physical therapy necessary to perform this training must be directly performed by the physical therapist as part of a one-on-one training program. The goal of physical therapy must be to train SCI patients on the use of NMES/FES devices to achieve walking, not to reverse or retard muscle atrophy.

(Italicized information about NMES for walking in SCI patients is from CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 160.12)

ICD-10-CM diagnosis code G82.20 must be present for payment to be made. However, while paraplegia of lower limbs is a necessary condition for coverage, the nine criteria above are also required. 97116 is the only code to be billed. It must be used for one-on-one face-to-face service provided by the physician or therapist.

Supportive Documentation Requirements (required at least every 10 visits) for 97116

• Objective measurements of balance and gait distance, assistive device used, amount of assistance required, gait deviations and limitations being addressed, use of orthotic or prosthesis, need for and description of verbal cueing
• Presence of complicating factors (pain, balance deficits, gait deficits, stairs, architectural or safety concerns)
• Specific gait training techniques used, instructions given, and/or assistance needed, and the patient’s response to the intervention, to demonstrate that the skills of a therapist were required

CPT 97124 – Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) (one or more areas, each 15 minutes)

Documentation must clearly support the need for continued massage beyond 6-8 visits, including instruction, as appropriate, to the patient and caregiver for continued treatment.

This code is not covered on the same visit date as CPT code 97140 (manual therapy techniques).

Massage chairs, aquamassage tables and roller beds are not considered massage. These services are non-covered.

Do not bill 97124 for percussion for postural drainage.

Supportive Documentation Requirements (required at least every 10 visits) for 97124

• Objective clinical findings such as measurements of range of motion, description of muscle spasms and effect on function
• Subjective findings including pain ratings, pain location, effect on function

CPT 97139 - Unlisted Therapeutic Procedure (specify) If an existing CPT code does not describe the service performed, an unlisted CPT code may be used. The use of unlisted codes should be rare. If unlisted codes are billed, the claim and medical record must clearly state what modality or procedure is billed as an unlisted code. If not, the unlisted code billed will be subject to denial for insufficient information.

Supportive Documentation Requirements for 97139 Please see section Documentation Requirements for Unlisted Procedure Codes.

CPT 97140 - Manual Therapy Techniques (e.g.,mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes

The goal of treatment is to reduce lymphedema of an extremity by routing the fluid to functional pathways, preventing backflow as the new routes become established, and to use the most appropriate methods to maintain such reduction of the extremity after therapy is complete. This therapy involves intensive treatment to reduce the volume by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program. Ultimately the plan must be to transfer the responsibility of care from the therapist to management by the patient, patient’s family, or patient’s caregiver.

The therapeutic exercise component for MLD / CDT is covered under CPT code 97110.

Documentation must clearly support the need for continued manual therapy treatment beyond 12-18 visits. When the patient and/or caregiver has been instructed in the performance of specific techniques, the performance of these same techniques should not be continued in the clinic setting and counted as minutes of skilled therapy.

CPT code 97124 (massage) is not covered on the same visit as this code.

Supportive Documentation Requirements (required at least every 10 visits) for 97140

• Soft tissue or joint mobilization technique used
• Objective and subjective measurements of areas treated (may include ROM, capsular end-feel, pain descriptions and ratings,) and effect on function
• For MLD/CDP, supportive documentation should include:
• medical history related to onset, exacerbation and etiology of the lymphedema
• comorbidities
• prior treatment
• cognitive and physical ability of patient and/or caregiver to follow self-management techniques;
• pain/discomfort descriptions and ratings;
• limitation of function related to self-care, mobility, ADLs and/or safety;
• prior level of function;
• limb measurements of affected and unaffected limbs at start of care and periodically throughout treatment;
• description of skin condition, wounds, infected sites, scars.

CPT 97150 - Therapeutic Procedure(s), Group (2 or more individuals)

Group therapy procedures involve constant attendance of the physician, NPP, therapist, or assistant, but by definition do not require one-on-one patient contact.

Supervision of a previously taught exercise program or supervising patients who are exercising independently is not a skilled service and is not covered as group therapy or as any other therapeutic procedure. Supervision of patients exercising on machines or exercise equipment, in the absence of the delivery of skilled care, is not a skilled service and is not covered as group therapy or as any other therapeutic procedure.

Report 97150 for each member of the group.

Group therapy consists of therapy treatment provided simultaneously to two or more patients who may or may not be doing the same activities. If the therapist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time , one unit of CPT code 97150 is appropriate per patient.

In a 25-minute period, a therapist works with two patients, A and B, and divides his/her time between the two patients. The therapist moves back and forth between the two patients, spending a minute or two at a time, and provides occasional assistance and modifications to patient A’s exercise program and offers verbal cues for patient B’s gait training and balance activities on the parallel bars. The therapist does not track continuous identifiable episodes of direct one-on-one contact with either patient. The appropriate coverage is one (1) unit of CPT code 97150 for each patient.

In a 45-minute period, a therapist works with 3 patients - A, B, and C - providing therapeutic exercises to each patient with direct one-on-one contact in the following sequence: Patient A receives 8 minutes, patient B receives 8 minutes and patient C received 8 minutes. After this initial 24-minute period, the therapist returns to work with patient A for 10 more minutes (18 minutes total), then patient B for 5 more minutes (13 minutes total), and finally patient C for 6 additional minutes (14 minutes total). During the times the patients are not receiving direct one-on-one contact with the therapist, they are each exercising independently. The therapist appropriately bills each patient one 15 minute unit of therapeutic exercise (CPT code 97110).

If group therapy is billed on a given day, it must be listed in the Treatment Note. The minutes of this untimed code must be added to the Total Treatment Time for that day. Further documentation describing the skilled nature of the group session documented in the progress report or the treatment note may assist in supporting the medical necessity of the service.

Supportive Documentation Requirements for 97150

• The purpose of the group and the number of participants in the group
• Description of the skilled activity provided in the group setting, such as instruction in proper form, or upgrading the difficulty of the activity for an individual.

CPT 97530 - Therapeutic Activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes

Documentation must clearly support the need for continued therapeutic activity treatment beyond 10-12 visits.

Supportive Documentation Requirements (required at least every 10 visits) for 97530

• Objective measurements of loss of ADLs, balance, strength, coordination, range of motion, mobility and effect on function
• Specific activities performed, and amount and type of assistance to demonstrate that the skills and expertise of the therapist were required

CPT 97129 (code effective 01/01/2020) – Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (on-on-one) patient contact; initial 15 minutes

CPT 97130 (code effective 01/01/2020) ;each additional 15 minutes (list separately in addition to code for primary procedure)

This activity is designed to improve attention, memory, and problem-solving, including the use of compensatory techniques.

Cognitive skills are an important component of many tasks, and the techniques used to improve cognitive functioning are integral to the broader impairment being addressed. Cognitive therapy techniques are most often covered as components of other therapeutic procedures, and, typically are better reported using other codes (such as 97535). Activities billed as cognitive skills development include only those that require the skills of a therapist and must be provided with direct (one-on-one) contact between the patient and the qualified professional/auxiliary personnel. These services are also reimbursable when billed by clinical psychologists.

Claims for cognitive skills development should include diagnoses that reflect the underlying condition requiring therapy, as well as the symptoms or manifestations of the condition.

Note: the restrictions placed upon this code do not apply to vision impairment rehabilitation services as defined in PM AB-02-078.

Supportive Documentation Requirements (required at least every 10 visits) for 97129, 97130

• Objective assessment of the patient’s cognitive impairment and functional abilities
• Prognosis for recovery of the specific impaired cognitive abilities (remediation)
• A determination of a range of compensatory strategies that the individual can realistically utilize to improve daily functioning in a meaningful way
• Specific cognitive activities performed, amount of assistance, and the patient’s response to the intervention, to demonstrate that the skills and expertise of the therapist were required

This service is payable to speech-language pathologists under certain conditions. More information on this coverage can be found in the Speech-Language Pathology LCD (L33580).

CPT 97533 – Sensory integration

Utilization of this service should be infrequent for Medicare patients.

Supportive Documentation Requirements (required at least every 10 visits) for 97533

• Objective assessments of the patient’s sensory integration impairments and functional limitations
• Describe the treatment techniques used that will improve sensory processing and promote adaptive responses to environmental demands, and the patient’s response to the intervention, to support that the skills of a therapist were required

CPT 97535 Self–care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes

IADL means activities related to living independently in the community, including but not limited to, meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community.

For example, as part of the initial occupational therapy program following a total hip arthroplasty (THA), a patient may need to learn adaptive lower extremity dressing techniques due to pain, limited ROM and hip precautions. The occupational therapist will need to evaluate the patient to determine the appropriate technique to be taught based on the patient’s unique assessment and will instruct the patient and/or caregiver in the special technique. Once the special dressing technique has been taught and monitored for safe completion, repetitious carrying out or practicing of the dressing technique would be considered non-skilled and would not be covered. Non-skilled interventions need not be recorded in the Treatment Notes as they are not billable. However, notation of non-skilled activities may be reported if the documentation indicates that the service was not billed (e.g., not included in the treatment minutes documented).

As the patient progresses through an episode of care involving self care/home management training, documentation needs to clearly support that the skills of a therapist continue to be necessary. Documentation that demonstrates progression in the technique to more complex or less patient dependence will assist in demonstrating that the technique remains skilled. It is important that documentation demonstrates that the skills of a therapist are needed and that the patient is not merely practicing techniques that have already been taught.   This code should be used for activities of daily living (ADL) and compensatory training for ADL, safety procedures, and instructions in the use of adaptive equipment and assistive technology for use in the home environment. See more specific codes for exercise training, orthotics, gait devices, etc.

This code should not be used globally for all home instructions. When instructing the patient in a self management program, use the code that best describes the focus of the self management activity. For example, if the instruction given is for exercises to be done at home to improve ROM or strength use 97110; if instructing the patient in balance or coordination activities at home, use 97112; if instructing the patient on using a sock aide for dressing, use 97535; if teaching the patient aquatic exercises to use as a independent program in the community pool, use 97113.

Supportive Documentation Requirements (required at least every 10 visits) for 97535

• Objective measurements of the patient’s activity of daily living (ADL)/instrumental activity of daily living (IADL) impairment to be addressed
• The specific ADL and/or compensatory training provided, specific safety procedures addressed, specific adaptive equipment/assistive technology utilized, instruction given and assist required (verbal or physical), and the patient’s response to the intervention, to support that the services provided required the skills and expertise of a therapist

CPT 97537 - Community/Work Reintegration Training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis) direct one-on-one contact, each 15 minutes

This code should be utilized when a patient is trained in the use of assistive technology to assist with mobility, seating systems and environmental control systems for use in the community.

For wheelchair management/propulsion training use 97542.

Coverage greater than 4-6 visits for community training should be justified by documentation to show the medical necessity of the length of treatment.

Supportive Documentation Requirements (required at least every 10 visits) for 97537

• Objective measurements of the patient’s community IADL impairment to be addressed
• Specific training provided, amount of assist required (verbal or physical), and the patient’s response to the intervention, to support that the services rendered required the skills of a therapist

CPT 97542 - Wheelchair Management (e.g., assessment, fitting, training), each 15 minutes

This code is used to reflect the skilled wheelchair management intervention clinicians provide related to the assessment, fitting and/or training for patients who must utilize a wheelchair for mobility. This service trains the patient, family and/or caregiver in functional activities that promote safe wheelchair mobility and transfers. Patients who are wheelchair bound may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications. Consider the following points when providing wheelchair management services.

Typically up to 3-4 dates of service should be sufficient to train the patient/caregiver in wheelchair management. Coverage beyond this utilization should have supportive documentation.

CPT Changes 2006 – An Insider’s View provides further clarification regarding the assessment portion of this code. A wheelchair assessment may include but is not limited to the patient’s strength, endurance, living situation, ability to transfer in and out of the chair, level of independence, weight, skin integrity, muscle tone, and sitting balance. Following verification of the patient’s need, patient measurements are taken of the patient prior to ordering the equipment to ensure accuracy of sizing wheelchair components. This measurement may also involve testing the patient’s abilities with various chair functions including propulsion, transferring from the chair to other surfaces (bed, toilet, car), and use of the chair’s locking mechanism on various types of equipment for optimal determination of the appropriate equipment by the patient and caregiver. For example, 97542 would be used when assessing and fitting the patient with a wheelchair and custom seating system to provide stabilization, support, balance, and pressure management. To achieve functional goals related to independent wheelchair management, 97542 would also be used when training the patient in the safe operation and management of the wheelchair in the home and community environment. (This example is based upon the Clinical Example for 97542 in the CPT Changes 2006 – an Insider’s View.)

There may be circumstances where a patient may be seen one time for a wheelchair assessment. If it is not necessary to complete a full patient evaluation, but only an assessment related to specific wheelchair needs, this one-time only session may be billed under 97542 with the appropriate units reflecting the time spent in the assessment. 

For many patient situations however, a full patient evaluation is needed to develop the appropriate treatment plan in addition to wheelchair fitting and training. In these situations, it may be appropriate to bill the initial evaluation code (97161-97163 or 97165-97167), with the minutes spent for the evaluation/assessment assigned to either 97161-97163 or 97165-97167. On the day that the evaluation code is billed, the minutes assigned to 97542 should only be related to any wheelchair fitting and training provided, as 97542 is a timed code. For example, if a physical therapist spends 35 minutes gathering the patient history, prior functional status, current functional status, social considerations, range of motion, strength, sensation, balance, and transfers, this time would be assigned to the PT initial evaluation code 97162. As the session continues, the PT spends 45 minutes assessing the patient in a variety of wheelchair set ups, trying a variety of adaptations to best meet the patient’s comfort and functional needs, and initiates training with the patient and family, this 45 minutes would be assigned to code 97542.

Supportive Documentation Requirements (at least every 4 visits) for 97542

• Documentation for a skilled wheelchair assessment should include the following:
• the recent event that prompted the need for a skilled wheelchair assessment;
• any previous wheelchair assessments have been completed, such as during a Part A SNF stay;
• most recent prior functional level;
• if applicable, any previous interventions that have been tried by nursing staff, caregivers or the patient that may have failed, prompting the initiation of skilled therapy intervention;
• functional deficits due to poor seating or positioning;
• objective assessments of applicable impairments such as range of motion (ROM), strength, sitting balance, skin integrity, sensation and tone;
• the response of the patient or caregiver to the fitting and training.

When billing CPT code 97542 for wheelchair management/training, documentation must relate the training to expected functional goals that are attainable by the patient and /or caregiver.

Describe the interventions to show that the skills of a therapist were required. For example, describe the various wheelchair adaptations trialed and the patient’s response to the intervention. If training is provided, describe the type of training, the amount of assistance required and the patient response to the training.

CPT 97545 - Work hardening/conditioning; initial 2 hours; and CPT 97546 - each additional hour These services are related solely to specific work skills and will be denied as not medically necessary for the diagnosis or treatment of an illness or injury.

CPT codes 97597 and 97598 : coverage criteria have been moved to the LCD for Debridement Services (L33614), effective 04/01/2016.  

C PT 97602  Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session Do not report 97602 in conjunction with 11042-11047

Medicare coverage for wound care on a continuing basis for a particular wound requires documentation in the patient's record that the wound is improving in response to the wound care being provided. It is not medically reasonable or necessary to continue a given type of wound care if evidence of wound improvement cannot be shown. Evidence of improvement includes measurable changes (decreases) in at least some of the following:

• inflammation;
• wound dimensions (diameter, depth);
• necrotic tissue/slough.

Such evidence must be documented periodically (e.g. weekly.) A wound that shows no improvement after 30 days requires a new approach, which may include a physician/NPP reassessment of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new treatment approach.

In rare instances, the goal of wound care provided in outpatient settings may be only to prevent progression of the wound, which, due to severe underlying debility or other factors such as inoperability, is not expected to improve. If this is the case, documentation should clearly indicate this rationale for continued skilled wound care.

Examples of Non-Selective Debridement (without anesthesia) (CPT 97602) include the following items.

• Blunt debridement
• Blunt debridement involves the removal of necrotic tissue by cleansing or scraping (abrasion). It may also involve the cleaning and dressing of small or superficial lesions.
• Enzymatic debridement
• Debridement with topical proteolytic enzymes is used as an adjunctive therapy in treating chronic wounds. The manufacturers’ product insert contains indications, contraindications, precautions, dosage and administration guidelines; it is the clinician’s responsibility to comply with those guidelines.
• Wet-to-moist dressings
• Wet-to-moist dressings may be used with wounds that have a high percentage of necrotic tissue. Wet-to-moist dressings should be used cautiously as maceration of surrounding tissue may hinder healing.
• Autolytic and chemical debridement

Documentation for each treatment must include a detailed description of the procedure and the method (e.g., scalpel, scissors, 4x4 gauze, wet-to-dry, enzyme) used when billing 97602. Because the correct debridement code is dependent on type of debridement and wound size, documentation should include frequent wound measurements. The documentation should also include a description of the appearance of the wound (especially size, but also depth, stage, bed characteristics), as well as the type of tissue or material removed. The documentation must meet the criteria of the code billed.

Additional guidance for debridement codes:

• Do not bill for more than one unit per session for CPT code 97602, regardless of the number or complexity of the wounds treated.
• Use the -59 modifier to indicate nonselective and selective debridement provided in a single encounter at different anatomical sites.
• Application and removal of dressings to the wound is included in the work and practice expenses of 97602 and should not be billed separately under a therapy plan of care. Charges for dressings, gauze, tape, sterile water for irrigation, tweezers, scissors, q-tips, and medications used in the wound care treatment will be denied even if the wound care service is found to be medically reasonable and necessary. Payment for dressings applied to the wound is included in HCPCS code 97602 and they are not to be billed separately.
• If a simple dressing change is performed without any active wound procedure as described by these codes, do not bill code 97602 to describe the service.
• For wound assessment it is not appropriate to bill therapy re-evaluation codes (97164, 97168) along with code 97602. The assessment, including measurements of the wound and a written report, is considered a part of code 97602.
• Patient and caregiver instructions are included in code 97602. Do not bill separately under any other code for instructing the patient/caregiver in care of the wound.
• This code represents “sometimes therapy” services and will be paid under the OPPS when (a) the service is not performed by a therapist, and (b) it is inappropriate to bill the service under a therapy plan of care. Nurses performing debridement (where allowed by state scope of practice acts) described by code 97602 may bill this code using revenue codes other than the therapy revenue codes 42x (PT) and 43x (OT).
• Payment for 97602, when performed by a qualified professional/auxiliary personnel under a therapy plan of care, is recognized as a bundled service under the Medicare Physician Fee Schedule (MPFS). Regardless of whether billed alone or in conjunction with another therapy code, separate payment is never made for 97602.
• Evaluation and management services should not be billed along with the debridement service unless a significant, separately identifiable evaluation and management service, correctly identified with modifier -25 on the claim, was also provided to the patient during the same encounter. (Therapists should not use the evaluation and management codes at any time.)

Supportive Documentation Requirements (required at least every 10 visits) for 97602

• Etiology and duration of wound
• Prior treatment by a physician, non-physician practitioner, nurse and/or therapist
• Stage of wound
• Description of wound: length, width, depth, grid drawing and/or photographs
• Amount, frequency, color, odor, type of exudate
• Evidence of infection, undermining, or tunneling
• Nutritional status
• Comorbidities (e.g., diabetes mellitus, peripheral vascular disease)
• Pressure support surfaces in use
• Patient’s functional level
• Skilled plan of treatment, including specific frequency, modalities and procedures
• Type of debridement performed, including instrument used, to support the debridement code billed
• Changing plan of treatment based on clinical judgment of the patient’s response or lack of response to treatment

Frequent skilled observation and assessment of wound healing are recommended daily or weekly to justify the skilled service. At a minimum, the Progress Report must document the continuing skilled assessment of wound healing as it has progressed since the evaluation or last Progress Report.

CPT 97605, 97606, 97607, 97608 – Negative pressure wound therapy (eg,vacuum assisted drainage collection), utilizing durable medical equipment (dme), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters.

CPT 97606 – surface area greater than 50 square centimeters

CPT 97607- Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters.

CPT 97608- Total wound(s) surface area greater than 50 square centimeters.  

Negative pressure wound therapy (NPWT) involves negative pressure to the wound bed to manage wound exudates and promote wound healing. NPWT consists of a sterile sponge held in place with transparent film, a drainage tube inserted into the sponge, and a connection to a vacuum source. CPT Codes 97607 and 97608 are reported when a mechanically-powered device is used.

Additional guidance for NPWT codes:

• These codes are not timed.
• Do not bill for more than one unit per session, regardless of the number or complexity of the wounds treated.
• Patient and caregiver instructions are included in codes 97605/97606 and 97607 and 97608. Do not bill separately under any other code for instructing the patient/caregiver in care of the wound.
• It is not appropriate to bill therapy re-evaluation codes (97164, 97168) along with 97605/97606 or 97607 and 97608. The assessment, including measurements of the wound and a written report, is considered a part of 97605/97606 or 97607 and 97608.

Supportive Documentation Requirements (required at least every 10 visits) for 97605, 97606, 97607 and 97608

CPT 97750 - Physical Performance Test or Measurement (e.g., musculoskeletal, functional capacity) with written report, each 15 minutes

These tests and measurements are beyond the usual evaluation services performed. Examples of physical performance tests or measurements include isokinetic testing, Functional Capacity Evaluation (FCE) and Tinetti. This code may be used for the 6-minute walk test, with a computerized report of the patient’s oxygen saturation levels with increasing stress levels, performed under a PT or OT plan of care on pulmonary rehabilitation patients.

The therapy evaluation and re-evaluation codes are for a comprehensive review of the patient including, but not limited to, history, systems review, current clinical findings, establishment of a therapy diagnosis, and estimation of the prognosis and determination and/or revision of further treatment. CPT 97750 is intended to focus on patient performance of a specific activity or group of activities (CPT Assistant, December 2003).

There must be written evidence documenting the problem requiring the test, the specific test performed, and a separate measurement report. This report may include torque curves and other graphic reports with interpretation.

97750 should not be used to bill for patient assessments/re-assessments such as ROM testing or manual muscle testing completed at the start of care (as this is typically part of the examination included in the initial evaluation) and/or as the patient progresses through the episode of treatment.

CPT code 97750 is not covered on the same day as CPT codes 97161-97168 (due to CCI edits).

Supportive Documentation Requirements (required at least every 10 visits) for 97750

• Problem requiring the test and the specific test performed
• Separate measurement report, including any graphic reports
• Application to functional activity
• How the test impacts the plan of care

CPT 97755 - Assistive technology assessment (e.g., to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes

This is an assessment code, per each 15 minutes, and must be accompanied by a written report explaining the nature and complexity of the assistive technology needed by the patient. This can include testing multiple components/systems to determine optimal interface between client and technology applications, and determining the appropriateness of commercial (off the shelf) or customized components/systems. This assessment may require more than one patient visit due to the complexity of the patient’s condition and his/her decreased tolerance for activity at one session.

Training for use in assistive technology in the home environment is coded as 97535 and for use in the community as 97537.

CPT code 97755 is not covered on the same day as CPT codes 97161-97168 (due to CCI edits). Utilization of this service should be infrequent.

Supportive Documentation Requirements for 97755

• The goal of the assessment
• The technology/component/system involved
• A description of the process involved in assessing the patient’s response
• The outcome of the assessment
• Documentation of how this information affects the treatment plan

CPT 97760 - Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes

Outpatient hospital therapy departments, comprehensive outpatient rehabilitation facilities (CORFs), outpatient rehabilitation facilities, nursing homes (limited to patients covered under a Medicare Part B stay), and home health agencies (limited to patients not under a HH plan of care) bill the Part A MAC for the orthotic utilizing the relevant HCPCS Level II L code and revenue code 274 on the claim form. These settings do not require a DME supplier billing enrollment to bill and be reimbursed for the L codes.

A physical or occupational therapist in private practice or a physician/NPP is considered by Medicare to be a "supplier" and must bill the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for orthotics. Any supplier that issues orthotics must be enrolled as a supplier of Durable Medical Equipment, Prosthetics, Orthotics, or Supplies (DMEPOS) prior to billing the DME MAC. Follow the directions from the DME MAC when billing for orthotics (utilizing an L code). Note: Therapists in private practice and physicians/NPPs should follow the guidance below for billing CPT 97760 to the Medicare carrier/Part B MAC.

Ongoing visits by the qualified professional/auxiliary personnel to apply the device would be considered monitoring. Once the initial fit is established, any further visits should be used for specific documented problems and modifications that require skilled therapy; these are billed with CPT 97763. It is reasonable and necessary to require 1-3 visits to fit and educate the patient or caregiver. The medical necessity of any further visits must be supported by documentation in the medical record.

Coverage under CPT code 97760 is not for prefabricated/commercial (i.e., off the shelf) components such as, but not limited to a lumbar roll, non-customized foam supports/wedges (e.g., heel cushions), or multi-podus boots. Such components do not require the skills of a therapist and are non-covered. Minor modifications to prefabricated orthotics do not constitute a customized orthotic.

Code 97760 should not be reported with 97116 for the same extremity.

Payment for prosthetics and orthotics is made on the basis of a fee schedule whether it is billed to the DME MAC or the Part A MAC.

The L codes for orthotics provide a brief description of the device and describe whether the device needs to be molded to a patient model, custom fabricated, custom fitted, or have no fitting specifications. Select the appropriate L code based on the description of the brace provided.

The Medicare payment for the L codes includes the following items.

• Assessment of the patient regarding the orthotic
• Measurement and/or fitting
• Supplies to fabricate or modify the orthotic
• Time associated with making the orthotic

CPT 97760 should be used to report the initial encounter for orthotic "training" completed by qualified professionals/auxiliary personnel. CPT 97760 may be used in conjunction with the L code only for the time spent training the patient in the use of the orthotic. Orthotic training may include teaching the patient regarding a wearing schedule, placing and removing the orthosis, skin care and performing tasks while wearing the device.

To avoid duplicate billing, the time spent assessing, measuring and/or fitting, fabricating or modifying, or making the orthotic may not be included in calculating the number of units to bill for CPT 97760 when also billing the appropriate L code. CPT 97760 is a "timed" code and only minutes actually spent in the training of the patient should be counted when determining units to bill when an L code is also billed.

There may be circumstances where a patient is only going to be seen for a brief therapy episode for issuance of an orthotic. If it is not necessary to complete a full, comprehensive patient evaluation, but only an assessment related to determining the specific orthotic, do not bill an initial therapy evaluation code in addition to the L code.

For other patient situations however, a full patient initial evaluation is needed to develop the appropriate treatment plan in addition to an assessment related to determining the specific orthotic. In these situations, it may be appropriate to bill the initial evaluation code (97161-97163 or 97165-97167), with the minutes spent for the evaluation assigned to either 97161-97163 or 97165-97167. For example, a patient is referred to occupational therapy for a wrist-hand orthotic with possible continued therapy. The OT spends 35 minutes evaluating the patient which includes the history, subjective complaints, prior and current functional levels, ROM, strength, sensation, skin integrity, and ADL assessment. This time would be assigned to the OT evaluation code 97165. The OT then begins the assessment of the patient for the orthotic which includes determining the need for the orthotic and the type of orthotic, subsequently fabricating the appropriate device and fitting it to the patient. This time, which takes 45 minutes, would be reimbursed under the L code. The OT spends an additional 20 minutes training the patient in the wearing schedule of the orthotic, skin care and exercises to be performed while the orthotic is in place. These 20 minutes would be assigned to code 97760, billable as 1 unit for the training component.

Per CPT Assistant, 2017, Code 97760 includes orthotic management and training provided at the initial encounter. Subsequent encounters, reported with code 97763 (effective 2018) include exercises performed in the orthotic, instruction in skin care and orthotic wearing time, and time associated with modification of the orthotic due to healing of tissues, change in edema, or interruption in skin integrity.

For an orthotic to be billed, it must be medically necessary for the patient's condition. To bill for training the patient to use the orthotic (CPT 97760) the documentation must justify the need for a skilled qualified professional/auxiliary personnel to train the patient in the use and care of the orthotic. When the management of the orthotic can be turned over to the patient, the caregiver or nursing staff, the services of the therapist will no longer be covered.

An orthotic provided for positioning and/or increasing range of motion in a non-functional extremity must include documentation that the unique skills of a therapist are required to fit and manage the orthotic and that the orthotic is medically necessary for the patient's condition.

It is not appropriate to bill CPT 97760 for measurements taken to obtain custom fitted burn or pressure garments. These garments do not fit the definition of an orthotic.

Supportive Documentation Requirements for 97760

• A description of the patient's condition (including applicable impairments and functional limitations) that necessitates an orthotic
• Any complicating factors
• The specific orthotic provided and the date issued
• A description of the skilled training provided
• Response of the patient to the orthotic

CPT 97761 - Prosthetic training, upper and/or lower extremity(s), initial prosthetic(s) encounter, each 15 minutes

Prosthetic training is the professional instruction necessary for a patient to properly use an artificial device that has been developed to replace a missing body part.

Prosthetic training includes preparation of the stump, skin care, modification of prosthetic fit (revisions to socket liner or stump socks), and initial mobility and functional activity training. Once a patient begins gait training with the prosthesis, use code 97116.

Supportive Documentation Requirements for 97761

• Type of prosthesis, extremity involved
• Specific training provided and amount of assistance needed
• Any complicating factors and specific description of these (with objective measurements), such as pain, joint restrictions/contractures, strength deficits, etc.

CPT 97763 - Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes

Per CPT Changes 2018, these assessments are intended for established patients who have already received their orthotic or prosthetic device, to check for skin integrity, wound changes, abnormalities of fit or a loss of function directly related to the device (e.g., pain, skin breakdown, and falls of devices or other problems related to the orthotic or prosthetic.

If the checkout assessment resulted in the need for further training in the use of the orthotic/prosthetic, code 97763 would be appropriate for the training.

Documentation must clearly support the need for more than 2 visits for the checkout assessment.

Supportive Documentation Requirements for 97763

• Reason for assessment
• Findings from the assessment
• Specific device, modifications made, instruction given

CPT 97799 - Unlisted physical medicine/rehabilitation service or procedure, not timed- If an existing CPT code does not describe the service performed, an unlisted CPT code may be used. The use of unlisted codes should be rare. If unlisted codes are billed, the claim and medical record must clearly state what modality or procedure is billed as an unlisted code. If not, the unlisted code billed will be subject to denial for insufficient information.

Supportive Documentation Requirements for 97799 Please see Documentation Requirements for Unlisted Procedure codes. This is an untimed code, billable as "1" unit.

CPT G0281 – Electrical stimulation, (unattended ), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care

CPT G0329 - Electromagnetic therapy , to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care

Do not bill a re-evaluation code for the wound assessment). If ES or electromagnetic therapy is being used, wounds must be evaluated at least monthly by the treating physician.

Per NCD 270.1, electrical stimulation (G0281) and electromagnetic therapy (G0329) are NOT COVERED for the treatment of:

• stage I or stage II wounds;
• electrical stimulation or electromagnetic therapy when used as an initial treatment modality;
• continued treatment with ES or electromagnetic therapy if measurable signs of healing have not been demonstrated within any 30-day period of treatment;
• wounds that demonstrate a 100% epithelialized wound bed;
• a patient in the home setting, as unsupervised use by patients in the home has not been found to be medically reasonable and necessary.

G0281 code replaces code 97014, only where it applies to treatment of wounds, as defined in the code narrative.

Nationally Covered Indications (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 270.1): Electrical stimulation (ES) and electromagnetic therapy for the treatment of wounds are considered adjunctive therapies, and will only be covered for chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers. Chronic ulcers are defined as ulcers that have not healed within 30 days of occurrence. ES or electromagnetic therapy will be covered only after appropriate standard wound therapy has been provided for at least 30 days and there are no measurable signs of healing. This 30-day period may begin while the wound is acute. Standard wound care includes optimization of nutritional status, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, and necessary treatment to resolve any infection that may be present. Standard wound care based on the specific type of wound includes frequent repositioning of a patient with pressure ulcers (usually every 2 hours), off-loading of pressure and good glucose control for diabetic ulcers, establishment of adequate circulation for arterial ulcers, and the use of a compression system for patients with venous ulcers. Measurable signs of healing include a decrease in wound size (either surface area or volume), decrease in amount of exudates, and decrease in amount of necrotic tissue. ES or electromagnetic therapy must be discontinued when the wound demonstrates a 100% epithelialized wound bed.

Supportive Documentation Requirements (required at least every 10 visits) for G0281 and G0329

• Type of prior treatments by a physician, non-physician practitioner, nurse and/or therapist that failed, including the duration of the failed treatment
• Skilled plan of treatment, including specific frequency of the modality
• Frequent skilled observation and assessment of wound healing (at least weekly, but preferably with each treatment session)

CPT G0282 - Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281

This code is not covered by Medicare.

Other Available Therapy Codes CPT Codes 95851, and 95852 - Muscle and Range of Motion Testing

For the typical patient, the evaluation (97161-97163, 97165-97167) and reevaluation codes (97164, 97168) include all the necessary evaluation tools, including range of motion and manual muscle testing. Baseline measurements may be done with an initial evaluation, but are not separately billable in addition to the evaluation. In addition, assessments, which are separate from evaluations and reevaluations, are included in the therapy treatment services and procedures and should be coded consistent with the intervention for which the assessment is necessary.

Every muscle or joint in the affected extremity or trunk section, as described in the code descriptor, must be tested when coding these procedures. For example:

CPT codes 95831-95834 are deleted for 2020. To report manual muscle testing, please refer to evaluation codes 97161-97168.

Code 95851 is “Range of motion measurements and report; each extremity (excluding hand) or trunk section (spine)”. To use this code for extremity ROM testing, every joint of an extremity would need to be tested, with documentation of why such a thorough assessment was warranted. It would not be appropriate to bill code 95851 if only shoulder ROM needed to be tested.

These codes are not covered on the same visit date as CPT codes 97161-97168 (due to CCI edits).

Supportive Documentation Requirements These codes are typically consultative. It is expected that the administration of these tests will generate material that will be formulated into a report. That report should clearly indicate the purpose and rationale for the test, the test performed with results and how the information affects the treatment plan.

Application of Casts and Strapping Codes  (29065, 29075, 29085, 29086, 29345, 29355, 29365, 29405, 29425, and 29445, 29200-29280, 28520-29590, 29799)

More than 8-10 visits for evaluation, treatment, modification and caregiver education would not be considered reasonable and necessary without significant documentation.

These are untimed codes.

General Guidelines for Strapping (CPT codes 29200-29280, 28520-29590, 29799. For dates of service prior to 2010, CPT code 29220 is used to report low back strapping, and for dates of service between 01/01/2010 and 09/30/2010, CPT code 29799 is used to report the service.)

A physician who applies the initial cast, strap or splint and also assumes all of the subsequent fracture, dislocation, or injury care cannot use the application of casts and strapping codes as an initial service, since the first cast/splint or strap application is included in the treatment of fracture and/or dislocation codes. A temporary cast/splint/strap is not considered to be part of the preoperative care.

Strapping is not always synonymous with taping (such as McConnell taping or kinesiotaping). See additional information on taping under codes 97110 and 97112. See code 97140 for wrapping techniques for manual lymphatic drainage.

For dates of service on and after 10/1/2010, low back strapping (regardless of CPT code billed) will be considered a non-reimbursable service under Medicare, as the service has been removed from CPT as an obsolete procedure [CPT Changes 2010 – An Insider’s View, page 91].

Special instructions for code 29580 – Strapping; Unna boot

Bilateral unna boots should be billed with a modifier -50 (bilateral procedure).

CPT 29799 - Unlisted procedure, casting or strapping

If an existing CPT code does not describe the service performed, an unlisted CPT code may be used. The use of unlisted codes should be rare. If unlisted codes are billed, the medical record and claim must clearly state what modality or procedure is billed as an unlisted code. If not, the unlisted code billed will be subject to denial for insufficient information. As of 10/01/2010, low back strapping (formerly CPT code 29220) should not be billed with CPT code 29799.

Supportive Documentation Requirements for 29799

This is an untimed code, billable as "1" unit. Please see section Documentation Requirements for Unlisted Procedure Codes.

General Guidelines for Splinting (Codes 29105-29131, 29505-29515)

See codes 97760 and 97762 for further information on orthotics.

According to CPT Assistant-February 2007, orthosis application differs from the purpose of an application of a cast or strapping device. Casting and strapping codes should not be reported for orthotics fitting and training.

This example is based upon a clinical vignette in CPT Assistant-April 2002.

Patient C is a 70-year-old female who presents to the outpatient orthopaedic clinic following a left ankle injury when her foot became twisted in her dog's run chain. After the orthopaedist evaluates the patient, radiologic views were obtained that substantiated the diagnosis of a sprained ankle ligament. A short-leg plaster posterior molded splint is applied by the physical therapist due to the degree of swelling (billable as CPT 29515). Upon return to the orthopaedic clinic, the splint is removed, x-rays repeated, and based on those findings, a short-leg fiberglass nonwalking cast is applied.

CPT 90901 – Biofeedback training by any modality

CPT 90912 – Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient

90913; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (list separately in addition to code for primary procedure)

Biofeedback therapy differs from electromyography which is a diagnostic procedure used to record and study the electrical properties of skeletal muscle. An electromyography device may be used to provide feedback with certain types of biofeedback. 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 Publication 100-03 , Medicare National Coverage Determinations (NCD) Manual, Section 30.1 )

Biofeedback for incontinence

Biofeedback is covered for the treatment of stress and/or urge incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training. Biofeedback is not a treatment, per se, but a tool to help patients learn how to perform PME. Biofeedback-assisted PME incorporates the use of an electronic or mechanical device to relay visual and/or auditory evidence of pelvic floor muscle tone, in order to improve awareness of pelvic floor musculature and to assist patients in the performance of PME.

A failed trial of PME training is defined as no clinically significant improvement in urinary incontinence after completing four weeks of an ordered plan of pelvic muscle exercises to increase periurethral muscle strength. 

When providing biofeedback procedures for urinary incontinence, use CPT 90901 when EMG and/or manometry are not performed. CPT 90912 and 90913 describe biofeedback that is more involved than conventional biofeedback measures (code 90901) and includes evaluations of the EMG activity of the pelvic muscles, urinary sphincter and/or anal sphincter by using sensors. This procedure can use manometry (measure of pressure of gases or liquids by use of a manometer) or EMG (electromyography - the recording of electrical activity initiated in the muscle tissue for testing purposes) to measure activity. The EMG activity is evaluated and provides objective information regarding the muscle activity and provides a basis for pelvic muscle rehabilitation utilizing biofeedback.

Additional documentation is necessary to justify biofeedback services beyond 5-6 visits. The descriptor for codes 90901 does not include a time element; therefore, this code should be billed as one (1) unit.

Supportive Documentation Requirements (required at least every 10 visits) for 90901 and 90912/90913 As noted in the NCD descriptions above, biofeedback is covered only when more conventional treatments such as heat, cold, massage, exercise (such as PME), and/or support have not been successful. Therefore, documentation must provide a clear history of the conventional treatments unsuccessfully tried before initiating biofeedback. Since biofeedback is only covered when there is a lack of response to other therapies, the lack of response to or contraindication to, other therapies must be noted in the patient's record.

Additionally for the treatment of incontinence, include:

• identification of the type and degree of incontinence, expectations from the treatment and the time frame in which an improvement is anticipated;
• clear documentation of the formal instruction, monitoring and follow-up of a prescribed course of PME;
• evidence of behavioral modification training including, but not limited to, bladder retraining and fluid intake modification;
• the use of a patient record-keeping system, such as a personal voiding diary, in evaluating and monitoring progress.

CPT 95992 – Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per day Coverage for 95992 is limited to the following condition:

H81.11-H81.13 BENIGN PAROXYSMAL VERTIGO

CPT 96125 – Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of a qualified health care professional’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.

For psychological and neuropsychological testing by physician or psychologist, see 96101-96103, 96118-96120

Code 96125 has been established to report these test procedures when performed by qualified health care professionals, such as SLPs and OTs. Code 96125 is a time-based code intended to be reported per hour, including the time administering the tests to the patient, interpreting the results, and preparing the report. Note that this code includes both face-to-face time and non-face-to-face time.

Clinical example: A 36 year old male with TBI from a MVA is referred to the health care professional for standardized cognitive performance testing following a recent discharge. The qualified health care professional selects and completes face-to-face administration of the appropriate standardized test(s) to examine the patient’s current level of functional cognitive performance. Raw and standardized scores are derived and analyzed. A written report is prepared by the qualified health care professional and sent to the referring physician.  

Miscellaneous Services (Non-covered)

The following are non-covered as skilled therapy services. This is not an all inclusive list.

• Iontophoresis, except as indicated for primary focal hyperhidrosis
• Low level laser treatment (LLLT)/cold laser therapy (report CPT 0552T, effective 7/1/2019, and additionally, 97037 effective 1/1/2024)
• Dry hydrotherapy massage (e.g., aquamassage, hydromassage, or water massage)
• Massage chairs or roller beds
• Interactive metronome therapy
• Loop reflex training
• Vestibular ocular reflex training
• Continuous passive motion (CPM) device setup and adjustments
• Craniosacral therapy
• Electro-magnetic therapy, except as indicated for chronic wounds
• Constraint Induced Movement Therapy (CIMT)
• Work-hardening programs
• Pelvic Floor Dysfunction (not including incontinence)
• pelvic floor congestion
• pelvic floor pain not of spinal origin
• hypersensitive clitoris
• prostatitis
• cystourethrocele
• vulvar vestibulitis syndrome (VVS)

Due to the lack of peer reviewed evidence concerning the effect on patient health outcomes, skilled therapy interventions (e.g., ultrasound, electrical stimulation, soft tissue mobilization, and therapeutic exercise) for the treatment of the following conditions is considered investigational and thus non-covered.

• Frequency Specific Microcurrent: non-covered due to lack of medical literature supporting the effectiveness of this therapy
• Whole body periodic acceleration: does not meet the benefit requirement that it requires the services of a skilled professional
• Light beam Generator therapy: non-covered due to lack of medical literature supporting the effectiveness of this therapy
• Functional Electrical Stimulating (FES) devices other than those that assist in walking are not covered under Medicare [NCD 160.12]. Consequently, any services related to the evaluation for or training of patients to use such a device is not covered. Such devices may include, but are not limited, to the Ergys® system.

General Documentation Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, the time of any assessment is included and billed within the appropriate treatment intervention CPT code . Therapy services shall be payable when the medical record and the information on the claim consistently and accurately report covered therapy services. Documentation must be legible, relevant and sufficient to justify the medical necessity of the services billed. Medicare requires a legible identifier of the person(s) who provided the service. The method used shall be a hand written or an electronic signature to sign an order or other medical documentation for medical review purposes. Electronic or hand written signatures that have been communicated through facsimile are also acceptable. Effective April 28, 2008, stamp signatures were no longer acceptable. The document guidelines in CMS Pub 100-02, Medicare Benefit Policy Manual , Chapter 15, Section 220 and 230 identify the minimal expectations of documentation by providers or suppliers or beneficiaries submitting claims for payment of therapy services to the Medicare program. It is encouraged, in order to support the medical necessity and the skilled nature of the treatment, to document more thoroughly and frequently. Medical review decisions are based on the information submitted in the medical record. Therefore, it is critical that the medical record information submitted is accurate and complete to allow medical review to make a fair payment decision. The medical record information submitted should:

• Paint a picture of the patient’s impairments and functional limitations requiring skilled intervention;
• Describe the prior functional level to assist in establishing the patient’s potential and prognosis;
• Describe the skilled nature of the therapy treatment provided;
• Justify that the type, frequency and duration of therapy is medically necessary for the individual patient’s condition;
• Clearly document both Timed Code Treatment Minutes and Total Treatment Time in order to justify the units billed;
• Identify each specific skilled intervention/modality provided to justify coding.

Documentation may be submitted in any format as long as all the necessary information is captured. Forms 700 & 701 are not required documents. The documentation must establish that the patient needs the unique skills of a therapist to improve functioning. This is accomplished through a description of the patient’s condition, and any complexities that impact that condition. Not only should documentation describe the needs of the patient that require the unique skills of a therapist, but should also describe the services provided that required the expertise, knowledge, clinical judgment, decision making and abilities of a clinician that assistants, qualified auxiliary personnel, caretakers or the patient cannot provide independently . A therapist’s skills may be documented, for example, by the descriptions of the skilled treatment, the changes made to the treatment due to an assessment of the patient’s needs on a particular treatment day, or due to progress judged sufficient to modify the treatment toward the next more complex or difficult task. Documentation should establish the variables that influence the patient’s condition, especially those factors that influence the therapist’s (or clinician's) decision to provide more services than are typical for the individual’s condition. Documentation should establish through objective measurements that the patient is making progress toward goals. When regression or plateaus occur, the reasons for the lack of progress should be noted to justify continued treatment. Only a clinician may perform an initial examination, evaluation, reevaluation and assessment or establish a diagnosis or a plan of care. The clinician may include as part of the evaluation or reevaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evaluation or reevaluation. The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.

Refer to CMS guidance on billing by PTAs and OTAs under https://www.cms.gov/Medicare/Billing/TherapyServices/Billing Examples Using CQ/CO Modifiers for Services Furnished In Whole or In Part by PTAs and OTAs.

Initial Evaluation (CPT codes 97161-97163, 97165-97167) The initial evaluation, which must be performed by a clinician, should document the medical necessity of a course of therapy through objective findings and subjective patient self-reporting. Documentation of the initial evaluation should list the conditions being treated and any complexities that make treatment more lengthy or difficult. Where it is not obvious, describe the impact of the conditions and complexities so that it is clear to the medical reviewer that the services planned are appropriate for the individual.

The initial evaluation establishes the baseline data necessary for assessing expected rehabilitation potential, setting realistic goals and measuring progress. Initial evaluations need to provide objective, measurable documentation of the patient’s impairments and how any noted deficits affect ADLs/IADLs and result in functional limitations. Functional limitations refer to the inability to perform actions, tasks and activities that constitute the “usual activities” for the patient. Functional limitations must be meaningful to the patient and caregiver, and must have potential for improvement. In addition, the remediation of such limitations must be recognized as medically necessary.

To support medical necessity, the evaluation should include the following items.

Presenting condition or complaint...."What brings the patient to therapy at this time?”

Patients should exhibit a significant change from their “usual” physical or functional ability to warrant an evaluation.

Provide an objective description of the changes in function that now necessitate skilled therapy. Simply stating “decline in function” does not adequately justify the initiation of therapy services.

Diagnosis and description of specific problem(s) to be evaluated

Include area of the body, and conditions and complexities that could impact treatment

Subjective complaints and date of onset

Relevant medical history

Applicable medical history, medications, comorbidities (factors that make therapy more complicated or require extra precautions)

Prior diagnostic imaging/testing results

Prior therapy history for the same diagnosis, illness or injury

If recent therapy was provided, documentation must clearly establish that additional therapy is reasonable and necessary

Social support/environment

What level of support is available, and what level of independence is required for the patient to be safe in the home environment?

Does the patient live alone, with a caregiver, in a group home, in a residential care facility, in a skilled nursing facility (SNF), etc.?

Does the home situation have obstacles that the patient must overcome (e.g., stairs without handrails)?

What are the patient’s usual responsibilities in the home environment?

Prior level of function

Key piece of information used for establishing potential, prognosis and realistic functional goals

Functional status just prior to the onset of the treating condition requiring therapy

Record in objective, measurable and functional terms

Functional testing

mobility status (transfers, bed mobility, gait, etc.);

self-care dependence (toileting, dressing, grooming, etc.);

meaningful ADLs/IADLs;

pain, and how it limits function; and

functional balance.

Objectively measure and/or describe the patient’s current level of functioning. Examples, based on the patient’s need, may include:

Objective impairment testing

Testing done to determine the source or cause of the functional limitation(s), such as ROM, manual muscle testing, coordination, tone assessment, balance etc.

Use concise, objective measurements. Avoid minimal/moderate/severe types of descriptions when more specific definitions or measurements are available. For example, when measuring shoulder flexion AROM, document degrees of motion, rather than documenting, “Shoulder flexion: minimal loss of motion.”

Summary of the therapist’s analysis of the condition being evaluated based on the examination of the patient. Clinical reasoning for treatment should be evident when further therapy is recommended.

Prognosis for return to prior functional status, or the maximum expected condition

Plan of care (see paragraph below)

Signature and credentials of the therapist or physician/NPP completing the initial evaluation and plan of care. Each therapy discipline must have a separate plan of care. The plan of care (POC) must contain ALL of the following information.

Re-evaluations (CPT codes 97164, 97168) See CPT 97164 and 97168 for coverage guidelines for therapy re-evaluations.

Re-evaluation documentation must include clear justification for the need for further tests and measurements after the initial evaluation, such as new clinical findings, a significant, unanticipated change in the patient’s condition, or failure to respond to the interventions in the plan of care. It is expected that clinicians continually assess the patient’s progress as part of the ongoing therapy services. This assessment is not considered a formal re-evaluation; the time of any assessment is included and billed within the appropriate treatment intervention CPT code.

Re-evaluations must be performed by clinicians and contain all applicable components of the initial evaluation. Resolved problems do not need to be re-evaluated; new or ongoing problems may need to be re-evaluated, especially if there is an anticipated change to the long term goals.

Progress Reports Progress reports provide justification for the medical necessity of treatment. Progress reports shall be written by a clinician at least once every 10 treatment days. Writing progress notes more frequently than the minimum is encouraged to support the medical necessity of treatment. A progress report is not a separately billable service. In CMS Publication 100-02, Medicare Benefit Policy Manual , Chapter 15, Sections 220-230, Medicare defines the minimum REQUIRED elements of a progress report. It is essential that clinicians include all required elements in their documentation (either in a progress report or treatment note). Progress note elements include (CMS required elements are italicized):

Date of the beginning and end of the reporting period that this report refers to;

Date that the report was written by the clinician, or if dictated, the date on which it was dictated;

Objective reports of the patient’s subjective statements, if they are relevant;

Objective measurements (impairment/function testing) to quantify progress and support justification for continued treatment;

Description of changes in status relative to each goal currently being addressed in treatment. Descriptions shall make identifiable reference to the goals in the current plan of care;

Assessment of improvement, extent of progress (or lack thereof) toward each goal;

Plans for continuing treatment , including documentation of treatment plan revisions as appropriate;

Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment;

Signature with credentials of the clinician who wrote the report.

No specific format is required to demonstrate patient progress as long as all information noted in the bullets above are included at least once in the medical record for each progress report period (10 treatment days). Progress report information may be included in the treatment notes, progress reports and/or formal re-evaluations (when re-evaluation guidelines are met). During each progress report period, the clinician must personally furnish in its entirety at least one billable service on at least one day of treatment. Verification of the clinician’s treatment shall be documented by the clinician’s signature on the treatment note and/or progress report.

Treatment Notes

Medical record documentation is required for every treatment day, and every therapy service to justify the use of codes and units on the claim. The treatment note must include the following required information:

date of treatment;

identification of each specific treatment, intervention or activity provided in language that can be compared with the CPT codes to verify correct coding;

record of the total time spent in services represented by timed codes under timed code treatment minutes;

record of the total treatment time in minutes, which is a sum of the timed and untimed services;

signature and credentials of each individual(s) that provided skilled interventions.

In addition, the treatment note may include any information that is relevant in supporting the medical necessity and skilled nature of the treatment, such as:

patient comments regarding pain, function, completion of self management/home exercise program (HEP), etc.;

significant improvement or adverse reaction to treatment;

significant, unusual or unexpected changes in clinical status;

parameters of modalities provided and/or specifics regarding exercises such as sets, repetitions, weight;

description of the skilled components of the specific exercises, training, or activities;

instructions given for HEP, restorative or self/caregiver managed program, including updates and revisions;

communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist);

communication with patient, family, caregiver;

equipment provided

any additional relevant information to support that the patient continues to require skilled therapy and that the unique skills of a therapist were provided.

If grid or checklist forms are used for daily notes or exercise/activity logs, include the signature and credentials of the qualified professional/auxiliary personnel providing the service each day. Listing of exercise names (e.g., pulleys, UBE, TKE, SLR) does not alone imply that skilled treatment has been provided, especially if the exercises have been performed over multiple sessions. Be sure to occasionally document the skilled components of the exercises so they do not appear repetitive and therefore, unskilled. Documenting functional activities performed (e.g., “ambulated 35 feet with min assist”, “upper body dressing with set up and supervision”) also does not alone imply that skilled treatment was provided. The skilled components/techniques of the qualified professional/auxiliary personnel used to improve the functional activity should be occasionally documented to support medical necessity.

When documenting treatment time, consistently use the CMS language of total “Timed Code Treatment Minutes” and “Total Treatment Time”. Do not use other language or abbreviations when referring to treatment minutes as it may be difficult for medical review to determine the type of minutes documented. The amount of time for each specific intervention/modality provided may also be recorded voluntarily.

Do not record treatment time as “Time in / Time out” for the entire session as this does not accurately reflect the actual treatment time. Do not “round” all treatments to 15-minute increments, but rather record the actual treatment time. Also do not record as “units” of treatment, instead of minutes. Only “intra-service care” of skilled therapy services should be reflected in the time documentation. Do not include unbillable time, such as time for:

waiting for treatment to begin;

waiting for equipment;

toileting; or

performing unskilled or independent exercises or activities.

Examples of treatment time documentation A treatment session includes 20 minutes therapeutic exercise (97110), 15 minutes therapeutic activities (97530) and 20 minutes unattended electrical stimulation (G0283). Time documentation in the treatment note

Timed Code Treatment Minutes: 35 minutes

Total Treatment Time: 55 minutes

A 30 minute OT initial evaluation is completed (97165), followed by 20 minutes fluidotherapy (97022). Time documentation in the treatment note

Timed Code Treatment Minutes: 0 minutes

Total Treatment Time: 50 minutes

Canalith Repositioning: Documentation should include:

- Results of physiologic testing (if performed)

- A plan for the continuing care,

- The progress demonstrated,

- The number of anticipated additional services,

- Explanation of why the patient would be unable to performing the exercises at home without the immediate supervision of a trained professional.

Discharge Notes

A discharge note is required for each episode of treatment and must be written by the clinician. The discharge note is a progress report covering the time from the last progress report up to the date of discharge, and includes all required components of a progress report. The discharge note may be considered the last opportunity to justify the medical necessity of the entire treatment episode. Therefore, if a discharge summary has been completed, it may be prudent to submit it with any request of records for medical review, even if the claim under review is for a treatment period prior to the date of discharge.

In the case of an unanticipated discharge, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified auxiliary personnel. In the case of a discharge anticipated within 3 treatment days of the progress report, the clinician may provide objective goals which, when met, will authorize the assistant or qualified auxiliary personnel to discharge the patient. In that case, the clinician should verify that the services provided prior to discharge continued to require the skills of a therapist. There must be indication that the clinician has reviewed the treatment notes and agrees to the discharge.

Certifications and Recertifications

Medicare beneficiaries receiving outpatient therapy services must be under the care of a physician/NPP. Orders (sometimes called referrals) and certifications are common means of demonstrating such evidence of physician involvement. Certification, which is a coverage condition for therapy payment, requires a dated physician/NPP signature on the therapy plan of care or some other document that indicates approval of the plan of care. A certification often differs from an order or referral in that it must contain all required elements of a plan of care. To assist medical review in determining that the certification requirements are met, certifications/recertifications should include the following elements(CMS required elements are italicized):

The date from which the plan of care being sent for certification becomes effective (for initial certifications, the initial evaluation date will be assumed to be the start date of the certified plan of care);

Long term treatment goals;

Type, amount, duration and frequency of therapy services;

Signature, date and professional identity of the therapist who established the plan; and

Dated physician/NPP signature indicating that the therapy service is or was in progress and the physician/NPP makes no record of disagreement with the plan. (Note: The CORF benefit does not recognize an NPP for certification.)

Effective January 1, 2008, the interval length shall be determined by the patient’s needs, not to exceed 90 days. Certifications which include all the required plan of care elements will be considered valid for the longest duration in the plan (such as 3x/wk for 6 weeks which will be considered as a total of 18 treatments). If treatment continues past the longest duration specified, a recertification will be required.

Documentation Requirements for Unlisted Procedure Codes (97039, 97139, 97799, 29799)

97039 - In addition to a detailed service description, information in the medical record submitted to the contractor must specify the type of modality utilized and, if the modality requires the constant attendance of the qualified professional/auxiliary personnel, the time spent by the qualified professional/auxiliary personnel, one-on-one with the beneficiary.

97139 - Information in the medical record and on the claim submitted to the contractor must specify the procedure furnished and also meet the other requirements for therapeutic procedures, i.e., the process of effecting change, through the application of clinical skills or services that attempt to improve function.

97799 - Information in the medical record submitted to the contractor must specify the service or procedure furnished, provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.

29799 - Information in the medical record submitted to the contractor must specify the service. It should also indicate the nature of the injury being treated and the anticipated outcome of the treatment.

Utilization Guidelines

The Medicare Physician Fee Schedule (MPFS) is the method of payment for outpatient therapy services, except critical access hospitals (CAH), which are paid on a reasonable cost basis. Although CAHs are not paid via the MPFS, all outpatient coverage, coding and documentation guidelines, as noted in the Medicare manuals and this LCD, apply.

Untimed CPT Codes When a therapy treatment modality or procedure is not defined in the AMA CPT Manual by a specific time frame (such as “each 15 minutes”), the modality or procedure is considered an “untimed” service. Untimed services are billed based on the number of times the procedure is performed, often once per day. Untimed services billed as more than “1” unit will require significant documentation to justify treatment greater than one session per day per therapy discipline. See the section “CPT 97161-97163 and 97165-97167” for additional guidance on billing for evaluations that span more than 1 day. The minutes spent providing untimed services are reflected in the documentation under “Total Treatment Time”(and are not included in the minutes for timed CPT codes when determining the number of timed-based units that may be billed).

Timed CPT Codes Many CPT codes for therapy modalities and procedures specify that direct (one-on-one) time spent in patient contact is 15 minutes. The time counted is the time the patient is treated using skilled therapy modalities and procedures, and is recorded in the documentation as “Timed Code Treatment Minutes.” Pre- and post-delivery services are not to be counted when recording the treatment time. The time counted is the “intra-service” care that begins when the qualified professional/auxiliary personnel is directly working with the patient to deliver the service. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment. The intra-service care includes assessment. The time the patient spends not being treated because of a need for toileting or resting should not be counted. In addition, the time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time. Time spent “supervising” a patient performing an activity that is defined as a timed code, or for the patient to perform an independent activity, even if a therapist is providing the equipment, is considered unbillable time and these minutes should not be counted in the “Timed Code Treatment Minutes.” Therapy timed services require direct, one-on-one patient qualified professional/auxiliary personnel contact, and by definition cannot be billed when performed in a supervised manner.

The first step when billing timed CPT codes is to total the minutes for all timed modalities and procedures provided to the patient on a single date of service for a single discipline. For example, a patient under an OT plan of care receives skilled treatment consisting of 20 minutes therapeutic exercise (CPT 97110) and 20 minutes self-care/home management training (CPT 97535). The total “Timed Code Treatment Minutes” documented will be 40 minutes. In addition, the combined time of 40 minutes will determine the total number of timed code OT units that shall be billed for the day. Whether a single timed code service is provided, or multiple timed code services, the skilled minutes documented in “Timed Code Treatment Minutes’ will determine the number of units billed. Once the minutes have been summed, use the chart below to determine the total allowable units, based on the total Timed Code Treatment minutes.

1 unit > 8 minutes through 22 minutes

2 units > 23 minutes through 37 minutes

3 units > 38 minutes through 52 minutes

4 units > 53 minutes through 67 minutes

5 units > 68 minutes through 82 minutes

6 units > 83 minutes through 97 minutes

7 units > 98 minutes through 112 minutes

8 units > 113 minutes through 127 minutes

When the total Timed Code Treatment minutes for the day is less than 8 minutes, the service(s) should not be billed. It is important to allocate the total billable units for timed services to the appropriate CPT codes based upon the number of minutes spent providing each individual service. Any timed service provided for at least 15 minutes, must be billed one unit. Any timed service provided for at least 30 minutes, must be billed two units, and so on. When determining the allocation of units, it is easiest to separate out each service first into “15-minute time blocks”. For example: 20 minutes of Therapeutic Exercise (CPT 97110) = one 15-minute block + 5 remaining minutes

At least 1 unit must be allocated to this code

38 minutes of Self-care/Home Management Training (97535) = two 15-minute blocks + 8 remaining minutes

At least 2 units must be allocated to this code

If 38 minutes of CPT 97535 is the only treatment provided, then 3 units would be billed. However, as demonstrated in the examples below, there may be treatment sessions in which the correct billing would only allow 2 units, based on the “remaining minutes”.

The “remaining minutes” (those minutes remaining after the “15-minute blocks” have been allocated) are considered when the total billable units for the day allow for an additional unit to be billed. See the following examples:

24 minutes of neuromuscular reeducation (CPT 97112)

23 minutes of therapeutic exercise (CPT 97110)

____________________________________________

47 total Timed Code Treatment minutes

Utilizing the chart above, 47 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first

24 minutes 97112 = one 15-minute block + 9 remaining minutes

23 minutes 97110 = one 15-minute block + 8 remaining minutes

Each code contains one 15-minute block; therefore, each code shall be billed for at least 1 unit. Since the total minutes allows for 3 units, the third unit shall be applied to the service with the most “remaining minutes” (97112 has 9 remaining minutes, whereas, 97110 has 8 remaining minutes). The correct coding is

2 units 97112 + 1 unit 97110

20 minutes of neuromuscular reeducation (CPT 97112)

20 minutes therapeutic exercise (CPT 97110)

________________________________________

40 total Timed Code Treatment minutes

Utilizing the chart above, 40 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first

20 minutes 97112 = one 15-minute block + 5 remaining minutes

20 minutes 97110 = one 15-minute block + 5 remaining minutes

Each code contains one 15-minute block, therefore, each code shall be billed for at least 1 one unit. As 3 units is allowed, a review of the “remaining minutes” is required to determine which code should be billed the additional unit. Since the “remaining minutes” for each service are the same in this example, either of the codes may be billed for the additional unit. The correct coding is either one of the following

1 unit 97112 + 2 units 97110

4 minutes assessing shoulder strength prior to initiating and progressing therapeutic exercise (CPT 97110)

32 minutes therapeutic exercise (CPT 97110)

7 minutes manual therapy (CPT 97140)

_______________________________________

43 total Timed Code Treatment minutes

Utilizing the chart above, 43 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first

36 minutes 97110 = two 15-minute blocks + 6 remaining minutes

7 minutes 97140 = zero 15-minute blocks + 7 remaining minutes

Code 97110 must be billed for at least 2 units as it contains two 15-minute blocks. To determine the allocation of the third unit, compare the “remaining minutes”, and apply the additional unit to the service with the most remaining minutes. The correct coding is

2 units 97110 + 1 unit 97140

18 minutes of therapeutic exercise (CPT 97110)

13 minutes of manual therapy (CPT 97140)

10 minutes of gait training (CPT 97116)

8 minutes of ultrasound (CPT 97035)

49 total Timed Code Treatment minutes

Appropriate billing for a total of 49 minutes is 3 units. To allocate those 3 units, determine the 15-minute blocks first

18 minutes 97110 = one 15-minute block + 3 remaining minutes

13 minutes 97140 = zero 15-minute blocks + 13 remaining minutes

10 minutes 97116 = zero 15-minute blocks + 10 remaining minutes

8 minutes 97035 = zero 15-minute blocks + 8 remaining minutes

Code 97110 shall be billed for at least one unit as it contains one 15-minute block. The additional 2 units billable (for a total of 3 units for the day), must be applied to the services with the greatest remaining minutes. The correct coding is

1 unit 97110 + 1 unit 97140 + 1 unit 97116

There are not enough total minutes for the day to allow billing for the ultrasound. However, the ultrasound will still be documented in the treatment notes.

7 minutes of neuromuscular reeducation (CPT 97112)

7 minutes of therapeutic exercise (97110)

7 minutes of manual therapy (97140)

___________________________________________

21 total Timed Code Treatment minutes

The clinician shall select which CPT code to bill since each service was performed for the same amount of time and only one unit is allowed. The correct coding is

1 unit 97112

1 unit 97110

1 unit 97140

For treatment sessions with both timed and untimed services, the units and time documented for any untimed CPT codes should not be included in the counting of units and time for the timed CPT codes for a calendar day. The minutes for the timed codes are reflected in the Timed Code Treatment Minutes, with the units allocated as described above. The untimed minutes are reflected in the Total Treatment Time, which is a combination of the timed code minutes and the untimed code minutes. Per CMS, it is important that the total number of timed treatment minutes support the billing of units on the claim, and that the total treatment time reflects services billed as untimed codes. For example:

35 minutes OT evaluation (CPT 97165)

25 minutes therapeutic exercise (CPT 97110)

8 minutes therapeutic activities (CPT 97530)

_____________________________________

Total Timed Code Treatment minutes = 33 minutes

Total Treatment Time = 68 minutes

The evaluation, being an untimed code, is billable as “1” unit. Do not include the evaluation minutes in the total timed code treatment minutes when determining the appropriate number of units to bill for the timed codes. 33 total minutes of timed codes is billable as 2 units. To allocate the 2 timed code units, break out the 15-minute blocks first

25 minutes 97110 = one 15-minute block + 10 remaining minutes

8 minutes 97530 = zero 15-minute blocks + 8 remaining minutes

Since code 97110 has one 15-minute block, at least 1 unit of 97110 shall be billed. To determine which code shall be billed with the second unit, compare the remaining minutes. Since code 97110 has more remaining minutes, the second timed code unit shall be applied to this code. Correct coding for this session is

1 unit 97165 + 2 units 97110

The medical record documentation will note that the therapeutic activities were performed.

40 minutes PT evaluation (CPT 97163)

20 minutes unattended electrical stimulation (CPT G0283-untimed)

10 minute therapeutic exercise for home exercise program (CPT 97110)

Total Timed Code Treatment Minutes = 10 minutes

Total Treatment Time = 70 minutes

The untimed services are billable as 1 unit each. 10 minutes for the timed code is billable as “1” unit. The correct coding for this session is

1 unit 97163 + 1 unit G0283 + 1 unit 97110

Payment for therapy services is based on the qualified professional/auxiliary personnel's time spent in treating the individual patient. For this reason, in the same time period (such as from 1:00 to 1:15) a clinician cannot bill any of the following pairs of CPT codes for therapy services provided to the same, or to different patients.

Any two CPT codes for "therapeutic procedures" requiring direct one-on-one patient contact (CPT codes 97110-97763)

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) or (b) above - (CPT codes 97032-97763), 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 97110-97763) with the group therapy CPT code (97150) requiring constant attendance, for example, group therapy (97150) with neuromuscular reeducation (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 evaluation or reevaluation code (CPT codes 97161-97168) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032-97039), therapeutic procedures (CPT 97110-97763) and group therapy (CPT code 97150)

Miscoded services may lead to improper payment, or if medically reviewed, denials of billed charges. Medical records must always support all HCPCS/CPT codes and units billed.

Do not bill for documentation time separately(except for CPT code 96125). This is incorporated in the HCPCS/CPT fee reimbursed for each individual service provided.

Do not code higher than what the procedure requires. Coding in this manner may allow the provider to collect inappropriate revenues without incurring additional costs.

Do not select the HCPCS/CPT code based on the reimbursement amount associated with a particular HCPCS/CPT. Rather select the HCPCS/CPT based on the code that most accurately describes the service actually provided and/or the intention of the treatment to achieve the desired outcome/goal.

Do not “unbundle” services/procedures. Unbundling refers to the practice of splitting a single payment code into two or more codes. This may lead to inappropriate multiple payments.

Do not bill separately for supplies used to provide therapy services, such as electrodes, theraband, theraputty, etc.

Therapists, or therapy assistants, working together as a “team” to treat a patient cannot each bill separately for the same or different service provided at the same time to the same patient. For example, if an OT and PT are co-treating a patient with sitting balance and ADL deficits for 30 minutes, then only 2 units total can be billed to the patient: either 2 units of OT only; 2 units of PT only; or 1 unit of OT and 1 unit of PT.

Utilization Guidelines and Maximum Billable Units per Date of Service

Rarely, except during an evaluation, should therapy session length be greater than 30-60 minutes. If longer sessions are required, documentation must support as medically necessary the duration of the session and the amount of interventions performed.

The following interventions should be reported no more than one unit per code per day per discipline; additional units will be denied: 97012, 97016, 97018, 97022, 97024, 97028, 97129, 97150, 97161-97168, 97605, 97606, G0281, G0283, G0329.

The following timed interventions should be reported no more than 2 (two) units per code per day per discipline; additional units will be denied: 97033, 97034, 97035, 97036.

The following interventions should be reported no more than 4 (four) units per code per day per discipline; additional units will be denied: 97032, 97110, 97112, 97113, 97116, 97124, 97130, 97530, 97533, 97535, 97537, 97542, 97760, 97761, 97763.

Canalith repositioning (95992) should generally be limited to five or fewer encounters. Sessions in excess of this parameter must be documented as to their need and why these exercises cannot be performed by the beneficiary without the supervision of trained professionals. Denials due to the limits described in this section of the article may be appealed.  

Response To Comments

Coding information, bill type codes, revenue codes, cpt/hcpcs codes.

This list represents common physical and occupational therapy services and is not all-inclusive.

HCPCS code G0295 is status N (non-covered) under Medicare.

CPT code 97037 is status N (non-covered) under Medicare.

CPT/HCPCS Modifiers

Icd-10-cm codes that support medical necessity.

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the related local coverage determination.

See the “Indications and Limitations of Coverage and/or Medical Necessity” section of the LCD. The specific condition for which therapy services are provided must be specified as the diagnosis supporting the medical necessity of each service.

Coverage for CPT code 95992 is limited to the following diagnoses:

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.

ICD-10-PCS Codes

Additional icd-10 information.

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. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Other Coding Information

Coding table information, revision history information, associated documents.

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Page Help for Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)

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CPT Codes For Physical Therapy Billing

What are cpt codes.

CPT is short for Current Procedural Terminology and the codes published by the American Medical Association. CPT codes are used to classify medical, surgical and diagnostic services and procedures, and range from 00100 to 99499. CPT, ICD-9 and ICD-10 are numeric representations of data that allow for more efficient data retrieval. Each classifies data much like a zip code identifies a specific area and makes it easier for the Post Office to sort the mail and deliver it quickly.

The Most Common Physical Therapy CPT codes:

Please note: CPT codes are copyrighted (1995-2023) by the American Medical Association. All rights reserved.

CPT, ICD-9 and ICD-10

While Physical Therapists use CPT codes to regiment the treatment of diagnoses, ICD coding is the standard international system for recording diagnoses and classifying mortality and morbidity statistics. The World Health Organization (WHO) created the ICD and still watches over it. ICD-9 was the ninth version of the ICD coding system, connecting the health issues of patients by using 3 to 5 digit alphanumeric codes. However, in 2015, ICD-10 (the 10th revision) was introduced, using 4 to 7 digit alphanumeric code. ICD-10 is now the standard of ICD coding.

In Physical Therapists’ offices, ICD-10 codes are used in combination with CPT codes, which identify the Physical Therapy service provided during the patient’s visit. Both codes are submitted to a payer for the Physical Therapist to be reimbursed. Ideally, the CPT code (treatment, service, procedure) matches up logically with the ICD-10 code (the symptom, injury, etc.). Reimbursement problems can arise when the CPT code doesn’t support the ICD-10 code.

Modifier 59

Modifiers are added to CPT codes when they are required to more accurately describe a procedure performed or service rendered. A modifier should never be used in order to receive a higher reimbursement or to get paid for a procedure that should be bundled with another code.

Let’s look at the CPT Manual definition of Modifier 59:

Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures [and/or] services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. 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.

This language can be a bit confusing, and the definition leans toward surgical procedures, however Modifier 59 does have its place in a Physical Therapy setting. It is also a potential red flag for the US Centers for Medicare and Medicaid Services (CMS) and commercial payers. When Modifier 59 is used incorrectly, it can lead to claim denial.

Modifier 59 is used to represent a service that is separate and distinct from another service it’s paired with. For therapists, Medicare uses the following example to explain the proper use of Modifier 59:

Column 1 Code / Column 2 Code – 97140/97530 >CPT Code 97140 – Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes >CPT Code 97530 – Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes Modifier 59 may be reported if the two procedures are performed in distinctly different 15 minute time blocks. For example, one service may be performed during the initial 15 minutes of therapy and the other service performed during the second 15 minutes of therapy. Alternatively, the therapy time blocks may be split. For example, manual therapy might be performed for 10 minutes, followed by 15 minutes of therapeutic activities, followed by another 5 minutes of manual therapy. CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same time block.

When is Modifier 59 Acceptable?

While the CPT Manual may give guidelines for the use of Modifier 59, the language is rather confusing and many Physical Therapists struggle with its use. Keep in mind the following:

• Submitting a claim containing both codes in an NCCI edit pair (also called linked services) will result in the payment of only one of the procedures. This happens because the payer will automatically assume that one of the procedures or services was built in to the other.
• If you didn’t actually perform the services together, then you can use Modifier 59 to let the payer know that each service in the edit pair was performed separate and independently of the other, and each service requires its own payment.
• Make sure you have the appropriate documentation that supports your billing decision. The final decision will come down to the details, and the more you can accurately document, the better off you will be. Never mislead or fake your documentation. Likewise, you shouldn’t get in the habit of using Modifier 59 with re-evaluation codes.
• Modifier 59 should be used as a last resort. If there’s a better option, use it instead. Frequently, a more descriptive modifier can be applied. Modifier 59 should only be initiated when it best fits the circumstances at hand.

Please be aware that in 2015, CMS created a new set of modifiers for use instead of Modifier 59 (in certain cases). These modifiers, such as XE, XP, XS and XU, are intended to bypass a National Correct Coding initiative edit by denoting a distinct encounter, anatomical structure, practitioner or unusual service. While the APTA has issued a statement that therapists do not need to use these new modifiers in place of Modifier 59, it’s probably just a matter of time before they are required to do so.

We will provide you with an update if we hear any changes on this policy.

Please note: New codes (as of April 2019) are shown in bold.

CPT Updates

Due to CPT changes on January 1, 2017, PTs and OTs can no longer use the following CPT codes when billing for initial evaluation and re-evaluation :

97001, 97002, 97003, and 97004

These four codes have been replaced by a set of eight evaluative codes – two for re-evaluation and six for evaluations.

The new codes for initial evaluation are tiered to designate the complexity of the evaluation.

Replacement CPT Codes for 97001

Replacement cpt codes for 97003, replacement cpt codes for 97002 and 97004.

If you need further explanation of the evaluation and re-evaluation codes, do not hesitate to contact your StrataPT account manager.

You May Also Like:

• The 8 Minute Rule: Medicare vs. AMA
• Real-Time Physical Therapy Practice Benchmarks
• Real-Time Physical Therapy Payer Benchmarks
• Medicare Fee Calculator
• Glossary of Physical Therapy Terms