Physical therapists spend countless hours working with clients to rehabilitate and strengthen after injury; it’s important that they are paid for their time spent, so they can stay in business and continue providing care. Billing insurance for physical therapy can be a tedious process, due to the level of specificity needed for maximum reimbursement. It’s important for physical therapists to have a strong understanding of how to bill both private insurance and Medicare for their services, to receive payment for their services.
Here, we’ve created a comprehensive guide to billing insurance as a physical therapist. We review the most common physical therapist billing codes to use, modifier codes to add, mistakes to avoid, billing for telehealth, and how billing works within Healthie for physical therapists.
Physical Therapy CPT Codes
There are a variety of different codes that can be used when billing for physical therapy; we are going to go over 13 of the most commonly used ones here. As of 2017, CPT codes 97001-97002 should no longer be used to bill for an initial evaluation or re-evaluation for physical therapy patients. From now on, for initial evaluations, providers should choose from one of three codes, that deem the level of complexity of the patient presents:
- 97161: Physical therapy evaluation, low complexity
- 97162: Physical therapy evaluation, moderate complexity
- 97163: Physical therapy evaluation, high complexity
Code 97002 was replaced with 97164: Re-evaluation of physical therapy established plan of care, and requires an examination to take place and a new revised plan of care to be presented. For Medicare, re-evaluation is needed every 10th visit or 30 days whichever comes first in outpatient setting.
For services typically provided by physical therapists, there are 10 codes that are most commonly used. The descriptions of these services are somewhat ambiguous, which is what makes billing for physical therapy such a difficult process. The language is left somewhat open-ended so that, if the insurance company doesn’t believe the service was medically necessary, they can easily deny your claim due to the CPT code used.
- 97110 Therapeutic Exercise: Exercises for strengthening, ROM, endurance, and flexibility; must be direct contact time with the patient
- 97112 Neuromuscular Re-Education: Activities that facilitate the re-education of movement, balance, posture, coordination, and kinesthetic sense
- 97116 Gait Training: Sequencing and training using a modified weight-bearing status, which employ assistive devices, and completing turns with proper form
- 97140 Manual Therapy: Soft tissue mobilization, joint mobilization, manipulation, manual traction, muscle energy techniques, and manual lymphatic drainage
- 97150 Group Therapy: The physical therapist provides a therapeutic procedure to two or more patients at the same time in a land or aquatic setting
- 97530 Therapeutic Activities: Any dynamic activities that are designed to improve functional performance
- 97535 Self-Care/Home Management Training: Includes a variety of techniques including ADL training, compensatory training, safety procedures/instructions, meal preparation, use of assistive technology devices or adaptive equipment
- 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
- 97761 Prosthetic Training: Includes fitting and training in the use of prosthetic devices as well as an assessment of the appropriate device
- 97762 Checkout for Orthotic/Prosthetic Use: Includes evaluation of the effectiveness of an existing orthotic or prosthetic device and recommendation for change
The payment received from the insurance company by the provider is based on the resource-based relative value scale. This means that providers are paid based on the work they perform, the expense to the practice, and the liability and risk in providing the services. It's important when comparing codes 97110 and 97530 for therapeutic activity; code 97530 tends to receive a higher reimbursement rate from insurance companies, because therapeutic activities take more skill and precision from the provider during the session. Healthie makes managing these payments even easier, and you can sign up for a Free Starter Plan here.
Timed vs. Untimed Codes for Medicare
For rehabilitation providers that bill Medicare, there are two different types of billing codes: untimed and timed codes. When using untimed codes, the PT is paid a predetermined fee, no matter the time spent on treatment. These codes can be billed once per treatment session. Timed codes are reimbursed based on the time spent working 1:1 with their patient, and include only skilled interventions. Timed codes can be billed multiple times per session, whereas untimed codes can only be billed once per session.
Technically, each timed code represents 15 minutes of treatment. However, because treatment may not always be split into perfect 15 minute segments, the 8-Minute Rule was devised. In order to bill one unit of time for a code, the provider must spend at least 8 minutes performing the service. To calculate the number of units to bill for timed codes, add up the total minutes spent and divide by 15. This will give you the number of units you can bill. If the remainder is more than 8, you can bill an additional unit; if it's 7 or under, you must bill for the minimum units.
If you need help organizing past sessions per these rules, or billing clients for treatments, Healthie’s Free Starter Plan makes it easy and streamlines future client scheduling and payment processing. Simply click here to get started today.
There are a variety of modifier codes that PTs can include on their insurance claim. One of the more confusing codes to use is Modifier 59. As defined by CMS: “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.” Providers can use Modifier 59 to identify any procedures or services that are not usually performed together, but were appropriate under the given circumstances. Modifier 59 is to be only used when there is no other appropriate modifier available, as a “last resort.”
However, the National Correct Coding Initiative has identified certain services that PTs commonly perform together; these are known as “edit pairs.” If you bill CPT codes that are part of one of these pairs, you’ll receive payment for just one of those codes. You must determine if you’re providing linked services or wholly separate services before using Modifier 59.
Modifier XE, XP, XS, and XU are modifier codes that can be used to bypass an edit pair, by claiming a distinct encounter, anatomical structure, or practitioner, or simply an unusual service.
Modifier GP indicates that the “services [were delivered] under an outpatient physical therapy plan of care.” Be sure to always include this code to ensure reimbursement.
Lastly, Modifier KX can be used when a patient has reached their physical therapy maximum for the year. On any claims with Modifier KX, the PT must document medical necessity for the continuation of care. Medicare can then request a review for any visits after the cap; the payment will be denied if medical necessity cannot be proven.
Physical Therapy Billing for Telehealth
While insurance reimbursement for telehealth services was primarily provided to medical doctors, there has been a dramatic rise in the reimbursement for virtual specialty services, including physical therapy. For physical therapists, offering virtual services can be a cost-effective way to expand your practice reach, retain clients and generate additional income for your business. Our patients and clients are becoming increasingly more interested in telehealth as time progresses, and it is important to consider offering telehealth within your practice. Healthie’s Free Starter Plan makes scheduling, offering, and billing for Telehealth appointments easy. To set up a free Starter account today, click here.
Within the United States, each state maintains its own jurisdiction with respect to the administration of telehealth services, including that by physical therapists. We recommend reviewing your state laws and regulations, as well as the guidance of your state practicing body, before implementing telehealth services in your care. Moreover, we recommend confirming with your liability insurance provider that your professional liability insurance covers telehealth services. You can read more on billing for telehealth here.
Common Billing Mistakes
✓ Billing to a Non-Billable Code
There are certain codes that will not be reimbursed if billed, specifically by Medicare and potentially a few other insurance companies. These include:
- 97014: Electric Stimulation Therapy
- 97010: Hot/Cold Packs
However, they usually will reimburse for 97302 Attended E-stimulation Therapy.
Additionally, there are certain codes that will be reimbursed up to one unit per visit. For time codes, one unit is equal to 8 minutes of care. The billing provider must clearly document the medical necessity for these services. The codes include:
- 97012: Mechanical Traction
- 97018: Paraffin Bath
- 97028: Ultraviolet
✓ Overusing or Using the Wrong Codes
Insurance companies tend to pay attention to the billing codes you use and how often you use them. If they see you using a certain code too often, they may audit you. Be sure to vary the codes you use to avoid an insurance audit and maximize your reimbursement.
Also be sure to use the specific, correct code when billing. Much of the services you can provide can fall under therapeutic exercise, even though it may fit better under another code, allowing for a higher rate of reimbursement.
Using Healthie for Physical Therapy Billing
Healthie offers a cloud-based EHR and telehealth platform that is quick to implement while supporting compliance with HIPAA regulations — while being customizable to meet your business needs. In addition, the Healthie platform integrates with insurance billing tools, so that you can quickly create Superbills and CMS 1500 claims, send invoices, and collect payments for out-of-pocket services. To set up a free Starter account today, click here.
Here’s what you gain when working with your physical therapy or occupational therapy clients via Healthie:
- Have a HIPAA and PCI compliant platform: prioritize the security and privacy of your clients while working together remotely.
- Immediate access to video calls: schedule and launch 1:1 and group virtual sessions, in-platform or through our Zoom integration — no additional fees required
- Transition your in-person appointments to virtual sessions: receive support from our team to import/transfer your data.
- Create message blasts + group chats with clients: streamline client communication.
- Remote patient monitoring: for clients that sync their wearables like Fitbit + iHealth.
- Ability for clients to log images and journal entries: for you to assess their progress between sessions.
We have seen physical therapists and occupational therapists that use Healthie find success with reimbursement for virtual services. Whether you’re a solo practitioner or part of a multi-provider group or organization, our flexible membership plans adapt to meet your business needs. Let us help you launch your practice.
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