Are the 11 Part B billing scenarios specific to pts and OTS?
As a result, the 11 Part B Billing Scenarios are specific to PTs and OTs. We will update this Web Page to reflect changes in policy (for example, CCI edits, new codes, new coverage determinations) that impact therapy billing and/or to provide clarification on billing policy for PTs, OTs and/or SLPs. Check the manuals first.
What is the CPT code for physical therapy evaluation?
Three new codes—97161, 97162, and 97163—replace the single 97001 CPT code for physical therapy evaluation
Can I Bill for evaluations and reevaluations?
However, you can bill for evaluations and reevaluations—in some cases. Most payers, including Medicare, allow therapists to bill for the initial evaluations necessary to establish plans of care.
How do the new evaluation and re-evaluation CPT codes work?
The new evaluation and re-evaluation CPT codes are not time-based, so the time it takes you to complete the evaluation and/or reevaluation doesn't factor in when determining which level of evaluation to report. The duration guidelines are just that: guidelines.
Which procedure code is used when billing an initial evaluation for PT?
Three codes — 97161, 97162, and 97163 — are used for physical therapy evaluation.
What is the KX modifier for Medicare?
The KX modifier, described in subsection D., is added to claim lines to indicate that the clinician attests that services at and above the therapy caps are medically necessary and justification is documented in the medical record.
How do you bill for functional capacity evaluation?
Current Procedural Terminology (CPT) Code 97750 is the procedure code to bill for functional capacity exams, including physical performance tests and measurements, and includes the writing of reports.
Can physical therapists Bill evaluation and management codes?
For evaluations/re-evaluations, physical therapists should use CPT code 97001 and CPT code 97002, and occupational therapists should use CPT code 97003 and CPT code 97004. For evaluation/re- evaluations physician/NPP should report the appropriate E&M code.
What is the KF modifier used for?
Although not associated with a specific , the KF modifier is required for claim submission of this HCPCS code as well. This information will be added to the applicable -related Policy Articles in an upcoming revision....Publication History.Publication DateDescription08/29/19Originally PublishedFeb 19, 2020
What is a GY modifier used for?
The GY modifier must be used when physicians, practitioners, or suppliers want to indicate that the item or service is statutorily non-covered or is not a Medicare benefit.
What is the CPT code for functional capacity evaluation?
97750CPT code 97750- is described as “Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes” The requestor appended modifier “FC” to code 97750.
What is functional capacity evaluation?
A functional capacity evaluation (FCE) evaluates an individual's capacity to perform work activities related to his or her participation in employment (Soer et al., 2008). The FCE process compares the individual's health status, and body functions and structures to the demands of the job and the work environment.
How often can physical therapy evaluation be billed?
State PT/OT Acts If a physical therapist assistant or physical therapy aide is involved in the patient care plan, a physical therapist shall reassess a patient every 60 days or 13 visits, whichever occurs first.
What codes can a physical therapist Bill?
Common Physical Therapy CPT Codes29240, 29530, 29540: Strapping.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.More items...•
Is physical therapy evaluation a timed code?
Timed codes require the furnishing provider (e.g., the therapist) to remain in constant attendance with—and/or provide constant contact to—the patient receiving the service....Common Timed PT Codes.97110Therapeutic Exercise97112Neuromuscular Re-Education97116Gait Training97035Ultrasound97033Iontophoresis3 more rows•May 25, 2021
Can you bill for chart review physical therapy?
There's a lot of confusion around whether PTs can bill for assessment and management time. The short answer is “yes,” PTs can—and should—account for assessment and management time in their billing and documentation.
Why do you need to bill for physical therapy?
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.
What is CPT medical?
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.”.
What software do providers use to submit claims?
Software. 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 ).
When to use modifier 59?
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 is a KX modifier?
The KX modifier is part of the therapy soft cap exceptions process. If you believe it is medically necessary for a patient who has already reached the cap to continue therapy—thus qualifying the patient for an exception—you would attach the KX modifier and clearly document your reasons for continuing treatment.
What is the most common claim form?
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.
How long does it take for a physician to sign a plan of care?
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.
How often is 97150 billed?
In private practice settings for physical and occupational therapists and in physician offices where therapy services are provided incident to the physician, Medicare expects the group therapy code (97150) to be billed only once each day per patient. In the facility/institutional therapy settings, the group therapy code could be applied more than once. However, the occasional situation where group therapy is billed more than once each day would require sufficient documentation to support its medical necessity and clinical appropriateness of providing more than one separate session of group therapy.
How long can a therapist bill for a supervised modality?
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.
Can a therapist bill a patient separately?
Therapists, or therapy assistants, working together as a "team" to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient.
What is 97164 in a re-evaluation?
Use: Re-evaluation (97164) This could include any improvement, decline, or other change in functional status that: you didn’t anticipate when you originally established the plan of care, and. requires further evaluation to ensure the best therapy outcomes.
What is 97164 in healthcare?
Use: Re-evalua tion (97164) If, during the course of care, you determine that the original plan isn’t having the intended effect on the patient, you may feel it necessary to change the plan of care. In this case, you would perform—and bill for—a re-evaluation.
How long do you have to wait to start a Medicare case?
Unfortunately, there isn’t a whole lot of solid guidance on this scenario. However, in the case of Medicare, if 60 days have passed, you must start the case over with an initial evaluation. That’s because Medicare automatically discharges a case when no claims have been submitted for 60 days. But again, this rule specifically applies to Medicare. For those patients with commercial insurances, you should defer to the payer—as well as your state practice act if it includes guidance on when evaluations and re-evaluations are appropriate.
What is 97164 in medical?
Use: Re-evaluation (97164) If you are treating a patient, and he or she presents with a second diagnosis that is either related to the original diagnosis or is a complication resulting from the original diagnosis, you’ll need to complete a re-evaluation and create an updated plan of care.
Can you re-evaluate after surgery?
Re-evaluations also may be appropriate for patients who received therapy treatment prior to surgery and then returned for additional rehabilitation after surgery. The catch in this situation is that some commercial payers may consider the post-op treatment period a new episode of care, in which case you’d need to use an evaluation code.
Should you defer to the payer for a rotator cuff evaluation?
For those patients with commercial insurances, you should defer to the payer—as well as your state practice act if it includes guidance on when evaluations and re-evaluations are appropriate . Example: You treat a 30-year-old carpenter for right rotator cuff weakness and discharge him or her from care.
How long do you have to bill Medicare for therapy?
According to the rule, you must provide direct treatment for at least eight minutes in order to receive reimbursement from Medicare for a time-based code. But, while it sounds simple, there are some tricky 8-Minute Rule scenarios that could trip you up.
What is an ABN in Medicare?
In order to provide Medicare patients with services that you believe are either not covered by Medicare or not medically necessary (e.g., the services extend beyond the therapy cap ), you must have your patient sign an Advance Beneficiary Notice of Noncoverage (ABN), thereby indicating that he or she will accept financial responsibility if—but really more like when—Medicare denies the claim.
What is modifier 59?
Modifier 59#N#If you provide two wholly separate and distinct services during the same treatment period—specifically, services that are typically bundled together—you may need to apply modifier 59 to signal that you should receive payment for both services. Download your printable modifier 59 decision chart here.
What is billable time?
1. Billable Time. To put it simply, billable time is time spent treating a patient. However, there are some nuances to keep in mind. For instance, you can’t bill for: unskilled prep time, multiple timed units due to multiple therapists, rest periods or other break times, supervision, or.
What is one on one therapy?
A one-on-one service is an individual therapy service—one that involves direct, one-on-one contact with a patient. While a group service still requires constant attendance, it does not involve one-on-one contact with each patient. Rather, according to CMS, it “consists of simultaneous treatment to two or more patients who may or may not be doing the same activities.”
Can you round up your billable time?
Additionally, when calculating your billable time, you shouldn’t ever round up . However, you can bill for evaluations and reevaluations—in some cases. Most payers, including Medicare, allow therapists to bill for the initial evaluations necessary to establish plans of care.
Can you waive copays?
If your patient’s insurance requires him or her 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 copayments or deductibles. However, there are other ways you can provide financial assistance to patients who need it. To learn more about what your payers consider acceptable when it comes to helping patients cover the cost of your services, thoroughly read your insurance contracts. If you still come up empty-handed, contact your payers directly.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
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.
Article Guidance
This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Outpatient Physical and Occupational Therapy Services L34049.
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.
Bill Type Codes
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.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
Spotlight
The Therapy Services webpage is being updated, in a new section on the landing page called “Implementation of the Bipartisan Budget Act of 2018”, to: (a) Reflect the KX modifier threshold amounts for CY 2021, (b) Add more information about implementing Section 53107 of the BBA of 2018, and (c) Note that the Beneficiary Fact Sheet has been updated.
Implementation of the Bipartisan Budget Act of 2018
This section was last revised in March 2021 to reflect the CY 2021 KX modifier thresholds. On February 9, 2018, the Bipartisan Budget Act of 2018 (BBA of 2018) (Public Law 115-123) was signed into law.
Other
On August 16, 2018, CMS issued a new Advance Beneficiary Notice of Noncoverage (ABN) Frequently Asked Questions (FAQ) document to reflect the changes of the Bipartisan Budget Act of 2018. Please find the document in the below Downloads section titled: “August 2018 ABN FAQs”.
Why do you need to conduct an expanded review of Rhonda's records?
Because Rhonda has such an extended history of physical, cognitive, and psychosocial issues that relate to—and impact— her current functional performance, you must conduct an expanded review of her records (i.e., one that is much more intensive than a patient with a brief medical history). Furthermore, after completing Rhonda’s OT assessment, you conclude she has seven performance-related deficits that hinder her ability to complete everyday activities and household tasks. However, even though the number of performance deficits exceeds the number included in the code description for a moderate-complexity evaluation, Rhonda’s case—as a whole—is not complex enough to warrant a high-complexity evaluation (remember, when there are elements of different levels of complexity in any given evaluation, you typically should code down). Thus, it makes sense to code for moderate complexity.
Is CPT time based?
The new evaluation and re-evaluation CPT codes are not time-based, so the time it takes you to complete the evaluation and/or reevaluation doesn't factor in when determining which level of evaluation to report. The duration guidelines are just that: guidelines.
Introduction
What Are The Codes?
- The International Classification of Diseases
In order to successfully bill for your services, you’ll need to 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… - The Current Procedural Terminology
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 …
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 oneto bring you back up to speed: 1. Treatment:Includes all therapeutic services. 2. 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 s…
What Are The Forms?
- Today, most payers—and providers—prefer electronic claim forms. 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 patientor a third-party payer. Occasionally, you may act…
What’s The Process?
- 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. Some payers—like Medicare—do … - 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 valu…
A Current Patient Develops A Newly Diagnosed, Related Condition.
A Current Patient Develops A Newly Diagnosed, Unrelated Condition.
- Use: Initial Evaluation (97161–97163) Conversely, when a patient with an active plan of care presents with a second condition that is totally unrelated to the primary issue, you should select the appropriate initial evaluation code. The nuance for therapists to remember is that a re-evaluation is triggered by a significant clinical change in the condition for which the original pla…
A Patient Undergoes Surgery Mid-Plan of Care.
- Use: Re-evaluation (97164) Re-evaluations also may be appropriate for patients who received therapy treatment prior to surgery and then returned for additional rehabilitation after surgery. The catch in this situation is that some commercial payers may consider the post-op treatment period a new episode of care, in which case you’d need to use an evaluation code. Example: You treat …