Physical Therapy Billing and Coding Guidelines

Physical therapy is a subspecialty that focuses on disabilities, injuries, and the enhancement of mobility and functional ability through assessment, diagnosis, and physical intervention. Effective claims processing and billing are critical components of any physical therapy practice. Prompt claim filing and reimbursement can make a significant difference in your financial strength.

Physical therapists assess your condition and provide an individualized care plan to guide your therapy. They may administer hands-on therapies to alleviate your problems. Additionally, they teach you unique workouts to improve your mobility and function.

Physical Therapy Billing and Coding Guidelines

In the majority of states, you can see a physical therapist without a referral from your physician.

 Or your doctor might prescribe it. Check your insurance policy to see if you need a prescription to cover the cost.

Your doctor might suggest this type of treatment if you’ve had an injury or illness that makes it hard to do daily tasks.

Physical therapy (PT) is care that aims to ease pain and help you function, move, and live better. You may need it to:

  • Relieve pain
  • Improve movement or ability
  • Prevent or recover from a sports injury
  • Prevent disability or surgery
  • Rehab after a stroke, accident, injury, or surgery
  • Work on balance to prevent a slip or fall
  • Manage a chronic illness like diabetes, heart disease, or arthritis
  • Recover after you give birth
  • Control your bowels or bladder
  • Adapt to an artificial limb
  • Learn to use assistive devices like a walker or cane
  • Get a splint or brace

Terminologies used in Physical Therapy Billing

Basics are everything when it comes to Physical Therapy Billing. Here is a list of a few terminologies that are basic yet inevitable:

  • 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. You can only bill one code, so it doesn’t matter if you complete these types of treatments in 5 minutes or 45.
  • Order/Referral: In some cases, a physician will provide an order for therapy that includes a diagnosis and instructions for treatment.
  • 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. It is at this point that the therapist provides diagnosis and prognosis.
  • 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 his or her therapeutic goals.
  • Initial certification: Medicare requires ordering physicians to approve or certify the plan of care via signature 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: Therapists must complete a progress report/not at minimum every tenth visit.
  • Discharge note: Once treatment is complete, therapists must complete a discharge note that details the patient’s treatment and status since the last progress note.

What Is Occupational Therapy?

This type of treatment can help if you have pain, injury, illness, or a disability that makes it hard for you to do your job or schoolwork, care for yourself, complete household chores, move around, or take part in activities.

Occupational therapy (OT) teaches you how to adapt. It can help you perform any kind of task at school, work, or in your home. You’ll learn how to use tools (you may hear them called assistive devices) if you need them.

You’ll meet with a health professional called an occupational therapist who can come up with ways to change your movements so you can get your work done, take care of yourself or your home, play sports, or stay active.

It can help you do specific things like:

  • Eat without help from others
  • Take part in leisure activities
  • Do office work
  • Bathe and get dressed
  • Do laundry or clean up around the house

What Is an Occupational Therapist?

They get special graduate training in occupational therapy. You’ll probably hear them called OTs. They must be licensed and pass a national exam to be certified to practice.

Some OTs go through more training so they can focus on certain types of treatment, like hand therapy, treating people with low vision, or working with children or older adults.

Occupational therapy assistants help with some parts of your treatment. They don’t assess you or create your therapy plan. An OT assistant needs an associate’s degree.

OT’s and OTA’s often work with your doctor, physical therapist, psychologist, or other health professionals.

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

  • PT evaluations (97161-97163) and OT evaluations (97165-97167), which are tiered according to complexity:
    • 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 (97597–97606)
  • Tests and measurements (97750–97755)
  • Orthotic and prosthetic management (97760–97762)

The physical therapist-specific CPT codes are located in the 97000 area, however, you may utilize any codes that are most pertinent to your service. Additionally, you must understand that just because your service is legally billable does not guarantee that the payer will repay you for it. As a result, always verify with your payer prior to submitting a claim.

The following are some of the most frequently used CPT codes that every Physical Therapist should be familiar with.

97012 – Mechanical Traction

97164 – PT Re-Evaluation

97113 – Aquatic Exercise

97150 – Group Therapy

97124 – Massage

97018 – Paraffin Bath

NC001 – No Charges This Visit

97163 – PT Evaluation: High Complexity

98941- Spinal, Three or Four Regions

97022- Whirlpool

97033 – Iontophoresis

98940 – Chiropractic Manipulative Treatment (CMT); Spinal, One or Two Regions

97039 – Laser/Other

97026 – Infrared Light

97110 – Therapeutic Exercise

97140 – Manual Therapy

97112 – Neuromuscular Re-Education

97530 – Therapeutic Activities

97010 – Hot/Cold Packs

97014 – Electrical Stimulation (Unattended)

G0283 – Electrical Stimulation, Medicare Non-Wound (Unattended)

97035 – Ultrasound/Phonophoresis

97161- PT Evaluation: Low Complexity

97116 – Gait Training

97162 – PT Evaluation: Moderate Complexity

97535 – Self Care/Home Management Training

97016 – Vasopneumatic Device

97032 – Electrical Stimulation (Manual)

97750 – FCE/Performance Test