How to succeed with physical therapy medical billing and coding

Physical therapy is becoming a busy sub-category of healthcare and includes categories like sports, geriatrics, trauma rehabilitation, women’s health, neurology, and wound management. Most physical therapists have their own clinics because therapy takes time, and the sessions are much longer than other medical sessions. One of the biggest challenges physical therapy practices face is handling administrative tasks, including billing and coding.

Did you know that the U.S. healthcare industry spends about one-third of its overall costs on administrative needs? Medical billing and coding are essential expenses because these determine the final reimbursements the practice or the hospital ends up with.

Physical therapy is a challenging department that few medical billing and coding companies can handle with the needed expertise.

There are different challenges in handling physical therapy billing and coding. We have tried to list a few major ones here.

Knowing the difference between one-on-one vs. group sessions

A physical therapist handles two types of therapy sessions – one-on-one and group sessions. When the billers start billing group sessions like they are individual ones, your practice may risk encountering a mandatory audit. Most of the claims may also be sent back denied.

When medical billing and coding companies bill individual sessions like group ones, you may not be able to get the financial worth of the services provided.

When the documents mention direct patient contact, your coder must use the one-on-one CPT codes. The number of units of therapy they can bill also depends on how many minutes of direct contact service was offered.

In some cases, the therapist may be able to charge for one-on-one rates even in group sessions when individual attention is given. By spotting this chance, the biller can improve the total revenue generated at the end of the month.

Talk to the medical billing and coding companies you are looking to hire and see if they understand the difference and have strategies to wade through these complexities.

Understanding the complexity of service rendered

Another unique feature that medical billing and coding companies need to know while billing and coding for physical therapy clients is the code groups here vary based on the complexity of the service rendered.

Depending on their complexity levels, there are three categories of codes for Physical Therapy (PT).

Code for PT Complexity level
97161 low complexity
97162 moderate complexity
97163 high complexity

Similarly, Occupational Therapy (OT) also has such categories of codes to be aware of.

Code for OT Complexity level
97165 low complexity
97166 moderate complexity
97167 high complexity

Apart from these, if the physical therapist has provided constant attendance to the patient, that could be billed in code categories between 97032–97039.

Therapeutic procedures, which are different from the regular therapy services offered, need to be coded using 97110–97546 codes.

You can see how intricate the code categories and their descriptions are. Only expert coders can play around with the codes to ensure you are legally correct in claiming reimbursements yet get your money’s worth.

Other Important Coding Guidelines for Physical Therapy

• Therapy evaluation and re-evaluation code should be billed under physical/occupational therapist (PT/OT)
• All timed therapy codes should have a minimum of 8 minutes of treatment timing.

Medicare’s 8 Minute Rule
Total Time Spent Performing Time-Based CPT Codes Number of Billable Units
8-22 Minutes 1 Unit
23-37 Minutes 2 Units
38-52 Minutes 3 Units
52-67 Minutes 4 Units
68-82 Minutes 5 Units
83 Minutes 6 Units

• When billing the therapy procedure codes 97530 and 97140 together, the records must states that these two procedures are performed in distinct 15 minutes time intervals.
• Medicare and Medicare replacement plan will not pay CPT code 97014 instead we should use HCPCS code G0283.
• Modifier KX should be billed with therapy codes when the cap limitation is met/exceeded
• CPT 97033 (Iontophoresis) is not payable when billed and the diagnosis on the claim is not primary focal hyperhidrosis (R61)
• Time-based CPT codes ;
a. therapeutic exercise (97110)
b. therapeutic activities (97530)
c. manual therapy (97140)
d. neuromuscular re-education (97112)
e. gait training (97116)
f. ultrasound (97035)
g. iontophoresis (97033)
h. electrical stimulation (manual) (97032)
• Service-based CPT codes;
a. physical therapy evaluation (97161, 97162, or 97163) or re-evaluation (97164)
b. hot/cold packs (97010)
c. electrical stimulation (unattended) (97014)

Wading through changing payer regulations

Medicare, Medicaid, and other insurance payers regularly change their terms and conditions. As they change their systems and processes, your billers and coders must keep up.

Quintessence differs from other medical billing and coding companies in the training and learning solutions we provide to our billers and coders. While all billers and coders go through mandatory training before joining us, we also ensure they regularly keep themselves updated with payer regulations by conducting expert training sessions.

This brings a positive difference in the services we render to clients.

If you have an in-house billing and coding team, ensure you have enough resources to train them regularly. If you hire third-party service providers, talk to them to understand how adept they are at updating their skills.

Handling complex coding challenges

When it comes to physical therapy, medical billing and coding companies need to focus specifically on coding because it is challenging. This segment of healthcare needs to use both ICD and CPT codes. ICD is used for the problems being treated, and CPT for the different treatments administered by the therapist.

This means that the coder needs to be comfortable handling thousands and thousands of different codes and, more importantly, know how to use them in the right places. Simple coding mistakes are common reasons why claims get denied in the first place.

A small group of coders may not be able to handle this, especially for large therapy practices. Here is where your coding team needs the support of the right technology.

Quintessence’s Codessence tool has been our outright support from day one. This ML-based tool is the only Computer Assisted Coding Software that uses Machine Learning technology and a 100% coder touch opportunity out in the market. Codessence can be tweaked to meet 100% audit compliances and quality requirements.

Conclusion

Suppose medical billing and coding companies want to succeed with physical therapy billing and coding. In that case, they should learn to handle all the above specific challenges, apart from the regular administrative burdens that come with the processes.

As a physical therapy practice, your billing and coding processes may look cumbersome and monotonous, but they determine the revenue you generate at the end of the day. Effective billing and coding ensure your claims pass through without having to go through rejections and denials. When they pile up, denied bills may turn expensive for the practice and can shake your financial stability.

It is time to explore your existing billing and coding process and find out performance gaps that need to be filled to improve efficiency. Experts from Quintessence may be able to study your existing RCM operations and help you improve them and make the right tweaks, so your operations can be your strategic advantage to help you grow as a practice.

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