On the WebPT Blog, we receive a whole lotta questions on a wide range of topics—from documentation best practices to setting a marketing budget. But one topic that comes up time and time again is what PTs can—or cannot—bill for. (And it makes a touch of sense considering that every PT practice relies on steady cash flow.) While some questions are super niche, many follow a set of common themes. With that in mind, we’ve compiled some of the physical therapy billing scenarios we’re asked about most frequently—and explained the “cans” and “can’ts” associated with them. Check ’em out below:
Physical therapists can bill for:
As of the publication date of this article, many states have allowed PTs to provide virtual services—if only temporarily. Furthermore, CMS has provisionally added PTs to its list of telehealth-eligible providers for the duration of the public health emergency period. On the commercial insurance side, many payers allow PTs to bill for telehealth services—some of which have had that policy in place since before the pandemic. Ultimately, you should check both your state practice act as well as each individual payer’s current rules regarding telerehab before you provide any virtual services.
For more specific information on telehealth billing, check out this WebPT Blog post.
2. Evaluation and Treatment on the Same Day
This is permissible as long as the treatment code either:
- doesn’t form an edit pair with the evaluation code, or
- forms an edit pair with the evaluation code that is eligible for modifier 59.
Now, for the details: The National Correct Coding Initiative (NCCI) has identified certain physical therapy services that PTs commonly perform together and dubbed these codes “edit pairs.” As a result, if you bill both codes in an edit pair on the same date of service, Medicare will only reimburse you for one of these codes. Fortunately, there’s a way around this in the form of modifier 59. If you performed these services as separate and distinct for one another—and your documentation supports this—you can affix modifier 59 to these codes and receive payment for both. That said, there are certain cases where two codes form an edit payer, but are not considered separate and distinct under any circumstances—even with the 59 modifier. To see which codes you can and cannot bill with evaluations, check out the charts here and here.
3. Therapeutic Massage
It’s always important to check your state practice act, but in most cases, physical therapists can bill CPT code 97124 (massage therapy) when they provide therapeutic massage.
One important thing to note: If you provide both manual therapy (CPT 97140) and therapeutic massage during the same treatment session, you may only receive payment for one of the associated CPT codes. The exception would be if you provided these services in separate 15-minute increments. If that is the case, affix the 59 modifier to the claim and be sure your documentation supports this.
Furthermore, when billing 97124 under Medicare Part B, PTs must affix the GP modifier to indicate this service was part of a physical therapy plan of care.
4. Maintenance Therapy
Yes, Medicare will pay for any services that meet its definition of medical necessity, which—as we explain in this post—means the services must:
- “Be safe and effective;
- Have a duration and frequency that are appropriate based on standard practices for the diagnosis or treatment;
- Meet the medical needs of the patient; and
- Require a therapist’s skill.”
According to the Jimmo v. Sebelius case, “coverage of skilled nursing and skilled therapy services in the Skilled Nursing Facility, Home Health, and Outpatient Therapy settings 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.” In other words, coverage is not contingent upon the beneficiary’s restoration potential. Instead, it’s dependent on whether or not skilled care is needed to meet the medical needs of the patient. So, if a Medicare patient requires continued therapy to maintain or prevent functional decline, then you should provide—and bill for—those services. (And make sure your documentation supports the medical necessity of said services.)
5. Durable Medical Equipment (DME)
Physical therapists can bill for DME, but they must first obtain a DMEPOS number. As we explain in this post, “Medicare considers physical therapists ‘suppliers,’ but DMERCs won’t see you that way until you obtain this number.” You’ll also need to be sure you pick the right code when billing for DME. Your options are as follows:
- 97760: Orthotics Initial Encounter Code
- 97761: Prosthetic Initial Encounter Code
- 97763: Orthotic and Prosthetic Management
For Medicare, therapists should use L-codes, which “are the HCPCS codes providers must use when billing for splints, braces, and any other services related to assessment, fabrication, and supplies—including follow-up.”
6. One-on-One Services in a Group
As this CMS resource states, Medicare allows direct one-on-one minutes to “occur continuously (15 minutes straight), or in notable episodes (for example, 10 minutes now, 5 minutes later).” So, if you’re working with more than one patient at the same time, you can bill for individual services if you are going back and forth and providing those services in “notable episodes.” This means if you provide direct, one-on-one skilled care to a patient for a cumulative total of 15 minutes, you can bill Medicare one unit of the appropriate timed service code. Just keep in mind that an individual therapy episode “should be of a sufficient length of time to provide the appropriate skilled treatment in accordance with each patient’s plan of care.”
For more details on billing for one-on-one versus group services, check out this post from the WebPT Blog.
7. Student-Led Services
Some providers wrongly assume that they can’t bill for a service simply because a student performed it. This is not the case when the therapist provides sufficient supervision. As we explain in this post, “To bill, the therapist must be actively engaged in providing care for the patient, directing the service, making skilled judgments, and providing checks and balances for the student.” Furthermore, “Therapists should never bill beyond what they would normally bill in the absence of student assistance.”
8. Dry Needling
While PTs can often bill for dry needling services, it ultimately depends on the state’s—and the payer’s—rules. Historically, there’s been a lot of debate regarding whether or not dry needling falls within the PT scope of practice and thus, whether or not PTs can even render this service—let alone bill for it. As a result, states and insurance payers are somewhat divided on the issue as well. However, as part of its 2020 final rule, CMS introduced two dedicated dry needling CPT codes:
- 20560: Needle insertion(s) without injection(s), 1 or 2 muscle(s)
- 20561: Needle insertion(s) without injection(s), 3 or more muscle(s)
This may sound like great news, but unfortunately, Medicare still considers these codes “non-covered,” meaning PTs will not receive reimbursement for them. However, now that CMS—and the AMA—has finalized these codes, PTs can use them when appropriate.
9. Diagnostic Ultrasound
This is another situation that’s payer-dependent. According to this resource from the APTA Orthopaedic Section, for private payers, “Qualified PTs can bill ultrasound imaging codes for a limited or complete musculoskeletal diagnostic examination. In many cases, ultrasound imaging is an adjunct to the primary procedure, such as therapeutic exercise or neuromuscular reeducation, and would not be payable as a separate procedure. Ultrasound imaging can also be billed as biofeedback, if used for that purpose.”
As for Medicare, the same resource explains that current Medicare rules do “not allow for PTs to order diagnostic imaging or be reimbursed for performing ultrasound imaging.” And again, before performing or ordering these procedures, you should check your state practice act for any specific language.
Physical therapists cannot bill for:
1. Documentation Time
As amazing as this would be, unfortunately, physical therapists cannot bill for the time they spend documenting. As Pauline Watts, MCSP, PT, and Danna D. Mullins, MHS, PT, explain in this article, “Documentation time alone is not considered billable time under Medicare regulations.” That said, there may be some instances where you can include the time you spend documenting as part of the billable service time. One such example Watts and Mullin provide is that of patient education, which includes any time dedicated to “discussing progress in therapy with the patient, including improvement in objective measures and how they are progressing toward their goals,” they write. “If we are documenting this patient education information at the same time we are providing it to the patient, then this documentation time can be included in the treatment time.”
Keep in mind that the patient must be an active participant in the conversation in order for it to count toward your billable time.
2. Progress Notes
As WebPT’s Erica McDermott mentions here, “As of January 1, 2013, therapists are required to complete a progress note for every Medicare patient on or before every tenth visit throughout that patient’s course of care.” That said, progress reports do not equate to evaluative visits (rather, CMS considers them a routine documentation best practice) and thus, cannot be billed as re-evaluations. According to WebPT President and Co-Founder Heidi Jannenga, re-evaluations are only appropriate if the patient presents with a new diagnosis or at least one of the following situations applies:
- “Through your own clinical assessment, you note a significant improvement, decline, or change in the patient’s condition or functional status that was not anticipated in the POC for that interval.
- “You uncover new clinical findings during the course of treatment that are somewhat related to the original treating condition.
- “The patient fails to respond to the treatment outlined in the current POC, and you determine that a change to the POC is necessary.
- “You treat a patient with a chronic condition and you don’t see him or her for treatment very often.
- “Your state practice act requires re-evaluations at specific time intervals.”
3. Occupational Therapy Services
Simply put, if a service is rendered by an occupational therapist, a physical therapist cannot bill for that service. However, most payers—including Medicare Part B—allow PTs and OTs to bill for services provided to the same patient on the same date of service. But keep in mind that, as Meredith Castin, PT, DPT, explains here, “therapists billing under Medicare Part B (i.e, outpatient) cannot bill separately for different (or the same) services provided to the same patient at the same time.
So, even if a PT and OT co-treat a patient with a low functional level in an outpatient setting for safety reasons, they cannot both bill for the entirety of their time. Instead, they must divide up their minutes based on the services each therapist provided.”
4. Patient Supervision
According to this CMS document, “Medicare pays only for skilled, medically necessary services delivered by qualified individuals, including therapists or appropriately supervised therapy assistants. Supervising patients who are exercising independently is not a skilled service.” It is safe to assume that most private payers adhere to this same rule.
5. Prep Time
As mentioned previously, Medicare only pays for skilled services. This means any non-skilled prep time (i.e., functions that can be carried out by a PT aide or other non-provider) is not reimbursable. As this document advises, “time counted as intraservice care begins when the therapist or physician or an assistant under the supervision of a physician or therapist is delivering treatment services. 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.”
This rule also applies to unskilled clean-up time. That said, as we note in this post, certain instances that can occur during clean-up time may qualify as skilled care, thus making them billable. An example would be “checking the patient’s skin for damage upon electrode removal.”
While these are some super common examples of services and activities for which PTs can and can’t bill, the list above is far from exhaustive. So, if you have some burning billing-related questions we didn’t answer here, be sure to register for this month’s live billing Q&A and get your answers straight from our rehab therapy billing experts.
The post 9 Things Physical Therapists Can Bill For—and 5 They Can’t appeared first on WebPT.