physical therapy CPT codes

The Ultimate Guide to Physical Therapy CPT Codes

Current procedural terminology (CPT) codes are used to designate services provided by healthcare professionals. We physical therapists receive compensation for our services depending on how we bill using these CPT codes. If we don’t properly bill for our services provided, we could be losing out on valuable income. This article aims to be an useful resource for new grads using physical therapy CPT codes.

While most of us got into this profession for the pure enjoyment of working with people who need our help, money still controls our profession, as it does in any other field.

The payment we receive for our services is based on the resource-based relative value scale (RBRVS), which takes into consideration the work performed, the expense to the practice, and the liability and risk in providing the services or procedures.

Now, I don’t know about you, but I sure didn’t learn much about proper billing when I was in PT school. This is one of the topics that we are expected to learn on our own as we embark on our clinical affiliations and careers.

Depending on the physical therapy setting in which you practice, and the site in which you are placed, you will find that people have different opinions on what constitutes proper use of these physical therapy CPT codes.

The billing black hole

I remember my first few months of trying to figure out how to properly bill in order to please the insurance companies and meet my own clinic’s expectations.

It was odd to me that there was so much widespread uncertainty involved in such a vital part of what we do on a daily basis as clinicians.

  • How could this topic be so sensitive and debatable?
  • Don’t insurance companies want to clearly define what procedures they will be paying for?
  • How will I know how to bill for my patients’ time in the clinic if I don’t truly understand what the codes even mean?

Those tasked with the job of creating and modifying Medicare legislation and reimbursement must have some idea of what they are doing. Payable criteria for each billing code must remain vague and undefined in order to give the insurance company the power to deny our claims if they feel our services aren’t necessary or warranted. To them, if a patient is considered “functional”, they no longer require skilled physical therapy intervention.

When it comes down to it, insurance companies are businesses. Their main job isn’t to provide affordable, high quality healthcare services to all who sign up for their services. Rather, their goal is to turn a profit.

The net profit of the industry over the past 10 years has equaled almost half a trillion dollars. Aetna alone reported a revenue of over $60.3 billion in 2015, a record for the company despite insurance companies sobbing over the passing of the Affordable Care Act in 2010.

Knowledge is power when it comes to physical therapy CPT codes

It would be fruitless to spend our valuable emotional energy struggling with the false idea that everyone who needs quality care will get the necessary funding from their insurance companies, especially since our patients already require so much of this energy on a daily basis.

We need to be informed of how to properly bill for our services to ensure small business success.

We need our private practice clinics to thrive so that they may continue to serve our communities and the patients who need us.

We owe it to our profession to be knowledgeable about how to properly and legally submit claims for our services. The future of reimbursement for physical therapy services may depend on it.

Know your value

For the reasons mentioned above, we must make sure that we write a fairly detailed description of the interventions that fall under each billing code we are using to submit our claims. We must be able to make an argument for what we are doing with our patients so that the insurance company sees we are providing high quality care for our patients and aren’t just trying to receive as much money as possible.

We must use the vague and barely defined codes to our advantage.

I know this sounds tough now that many of our clinics have been forced to increase patient volume in an effort to combat decreased reimbursement rates across the board, but the extra effort is worth it. The truth is that we are underpaid for what we provide. We now have a doctoral level of education. Let’s show the insurance companies how much we know and how valuable our skillset is.

Don’t let low insurance reimbursement dictate your self worth as a healthcare provider. Nobody else can provide the service we provide.

Simplifying the billing process

The main purpose of this article is to not only provide some insight on proper use of physical therapy CPT codes, but to spark some debate on the topic among providers. I want us to air out our frustrations and help each other understand the topic by providing personal accounts and information regarding what these codes mean and the criteria for which they should be utilized.

While the topic of billing can be complex, the focus of this particular article is to provide basic information every physical therapist should know about using these billing codes.

Billing terminology

In this section, I am going to outline some of the billing terminology that is useful in order to understand how to use physical therapy CPT codes.

Untimed codes: The PT is paid a predetermined fee regardless of the time of treatment application or the number of body areas being treated. These codes can only be billed once per treatment session. The time spent providing these services cannot be included in your calculations of timed units and are considered separate billing codes.

Timed codes: These codes are based on the time spent one-on-one with the patient and include only skilled interventions. Time includes pre-treatment, actual treatment, and post treatment time.

Pre-treatment time: Includes assessment and management, assessing patient progress, inspection of the tissue or body part, analyzing results of the previous treatment, asking questions, and using clinical judgment to establish the day’s treatment. All of the contact time is administered by the PT or PTA.

Intra-treatment time: Time spent providing the intervention.

Post-treatment time: This includes time spent analyzing the patient’s response to intervention, educating the patient, giving advice, documentation, or communicating with other healthcare professionals on the patient’s behalf. The patient must be present during this period of time in order to include it in the time calculation.

Medicare 8-Minute Rule:

1 unit of treatment time = 8-22 minutes
2 units of treatment time = 23-37 minutes
3 units of treatment time = 38-52 minutes
4 units of treatment time = 53-67 minutes
5 units of treatment time = 68-82 minutes
6 units of treatment time = > 83 minutes

Rule of mixed remainders: This is where things tend to get confusing. Try this example: You just spent 24 minutes on exercises in which you billed 1 unit of therapeutic exercise and 1 unit of neuromuscular re-education. Now let’s say you spent an additional 7 minutes performing manual therapy and another 4 minutes using iontophoresis. According to Medicare guidelines (8-Minute Rule), you can combine this extra time (11 minutes total) into one additional unit of manual therapy since the sum of your remainders was more than 8 minutes (you bill for the service that you provided more of, hence, manual therapy in this case).

However, according to American Medical Association (AMA) guidelines, leftover minutes that fall into multiple categories with less than 8 minutes per category cannot be billed for. This is why it is important to know which insurance company follows what guidelines.

Now that we’ve got some of the important details out of the way, let’s start talking about what I believe constitutes each of the used physical therapy CPT codes. I have done extensive research on the topic, only to find that not much information actually exists.

I will be basing the information on my research, what I feel makes sense to me, and what I have learned from coworkers and clinical instructors in the past.

Common physical therapy CPT codes and their usage

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About Nicholas Mazzone

Nicholas Mazzone
Nick is a physical therapist and certified strength and conditioning specialist from Staten Island, NY. He earned his doctorate in physical therapy from Stony Brook University in 2016. Nick currently works in an outpatient orthopedic sports clinic and is an independent contractor working with pre-school and school-aged children in Staten Island, NY.

2 comments

  1. Timothy McCullough

    Excellent refresher on CPT codes. I can pretty much guarantee that I’ll be coming back to this article if I need clarity on billing. Well written!

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