Integral to any outpatient physical therapy practice is the ability to bill and be paid for the services you provide. It is crucial to understand all the ins and outs of billing, so your process goes smoothly, and you get paid on a timely basis. In this article general billing and coding guidelines will be covered so you are equipped to understand how all this works and you can successfully bill for your services.
The International Classification of Diseases, 10th Revision, Clinical Modification or ICD-10-CM codes are diagnosis codes used to designate the patient’s primary diagnosis, condition, problem or other reason for their visit to see you. These codes are found in the ICD-10-CM codebook which can be purchased in a hardcopy or can be accessed through a zip file on the CMS website. One caution, attempting to find multiple appropriate codes in a zip file can be very frustrating and time consuming. It is worth it to purchase the book just because it’s easier to find your way through the book and utilize all appropriate codes.
All payers use the ICD-10 codes to get a picture of the patient and why they are seeking your care. Coverage and authorization decisions are based on whether the nature and extent of the patient’s problem warrants the insurer paying for that care. There are 12 slots on the billing claim form for ICD-10 codes so there is plenty of opportunity to accurately describe your patient through the codes.
When designating the diagnosis, the first code should be for the main diagnosis you are treating. You should then use additional codes to further describe the patient’s full condition or any co-morbidities that directly affect your care.
With that in mind, it is critical that you code accurately and completely. Then it’s equally crucial that your documentation matches up with the diagnosis codes, so you effectively justify your care. It’s also vitally important that you provide as many diagnosis codes as are appropriate. This helps the insurance company fully understands the complexity of the patient’s problems.
There are codes designated for injuries, signs and symptoms that accurately depict those diagnosis. There are also codes for Aftercare and those are designed for conditions such as post-surgery. In the case of surgery, you are not treating the condition the patient had surgery for you are treating the aftermath of that. For example, for the patient with OA of the knee who’s had a total knee arthroplasty, you are not treating the OA you are treating the aftereffects of the TKA. That makes an Aftercare code the primary code.
When billing for interventions provided in your services you will use the Common Procedural Terminology Codes to describe what those interventions were and how much of those interventions you delivered to the patient. Most of the CPT codes used by PT’s are in the 97000 series (Physical Medicine and Rehabilitation Section) in the CPT code book. However, you are not confined to only those codes. You may bill any code in the CPT code book if it falls within your state’s scope of practice regulations.
These interventions are divided into timed and untimed codes. Timed codes are expressed in 15-minute units. Each unit has a fee assigned to it, although these fees vary by insurance company contracts. These intervention codes are defined clearly in the CPT code book so you can determine which code can be used with any intervention.
It’s important to know these are legal definitions so you cannot re-interpret them as you wish. It’s also vital to know the code definitions apply regardless of the insurance company, e.g., the definitions are the same when billing Medicare or Cigna.
Per the CPT code book directions, for timed codes you may bill 1 unit for each 15 minutes of that intervention you provide. For example, if you provide therapeutic exercises for 15 minutes to a patient with low back pain you my bill 1 unit of Therapeutic Exercise CPT code 97110. If you provide 30 minutes of Ther Ex you may bill 2 units of 97110.
Another unit may be billed if the intervention is provided for an additional 8 min or more. An example here is, if you provide 23 minutes of therapeutic exercises you may bill 2 units of 97110. Billing Medicare becomes more complicated because you need to consider the total time for your interventions to determine the number of units you may bill. This is best explored by looking at the Local Coverage Determinations at your Medicare Administrators website or at the MW Therapy Blog on Medicare’s 8-minute rule.
Untimed codes are those interventions that, no matter how much of that intervention you provide, you will be paid the same fee. Simple examples are hot/cold packs or unattended electrical stimulation.
One additional issue is that all insurers require that an episode of physical therapy care be initiated by an evaluation that is bill through one of the 3-tiered Evaluation codes. These were established in January 2017 and are divided into low complexity, moderate complexity, and high complexity. There are relatively clear definitions/criteria for what type of patient would be assigned to each level. These can be found on the CMS website. Unfortunately, Medicare does not pay differently for each of these evaluation levels although it’s likely in the future they will create that differential.
The 1500 Form and its electronic equivalent are the standard for outpatient and outpatient in the home billing. A quick Google search of this form will show you the vast number of fields that must be filled in for the claim to be considered clean enough to process and pay you. If the form is not completely correct the claim is rejected, and you must re-submit with the corrected information. This can be frustrating, time-consuming and cost you money.
Virtually all practices utilize electronic billing now to submit bills directly to payers or through billing clearinghouses. In either process a clean claim, one with no errors, can be prepared which helps prevent the need to re-bill and chase your payments. Regardless of how you bill you must be sure your billing process is compliant with HIPAA standards. Billing is a covered entity in this law so you must ensure your process meets all those standards. Electronic billing will help ensure HIPAA compliance from a billing perspective.
If you are considering or already use an EMR then that vendor should be an excellent resource for you as well. It is vitally important the you understand the processes, rules and regulations so you avoid any legal consequences and are paid appropriately for your hard work.
This guide is to help you get a basic understanding of some of the issues and requirements for billing for your physical therapy services. There are numerous resources at APTA, CMS and other payer websites.
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