Physical Therapy Medicare Billing Guidelines

As physical therapists, there are many aspects of our jobs that we truly enjoy, the main one being helping our patients return to their previous quality of life following an injury or issue. However, like many other jobs, not everything we do is as exciting or fun, but rather more of a necessity so that our clinic is reimbursed and we are able to get paid! Today we are going to discuss what just might be the worst part of our job: billing. There is so much to remember when it comes to billing and several insurances have different standards, such as acceptable CPT codes, number of units that can be billed, different reimbursements once you bill more than once for a specific code in the same session, etc. For this blog though, we will be specifically focusing on Medicare billing guidelines as Medicare has a whole different set of rules, compared to most other insurances. Let’s begin.

Following the initial evaluation, you will have to enter ICD-10 codes to open a billing claim. ICD-10 codes are typically provided by the MD, but not always, specifically in states where direct access to PT services is allowed. If ICD-10 codes are not provided to you, then choose the most specific code or codes that accurately reflect the patient’s condition/why they showed up to therapy today, based on your evaluation.

After entering your ICD-10 codes, then you will have to put in your CPT codes which are really the “meat” of your billing as this is often the portion of billing that is questioned or put under a microscope when being reviewed. CPT codes reflect the services you provided during that visit and are required for billing each session. When billing, most of the CPT codes for physical therapists can be found under the 97000 section. For initial evaluations, there are a few options to choose from, as evaluations are categorized based on complexity (low, medium or high). To find out more information on which complexity level your patient falls under, click here to learn the differences between each category. CPT codes also include therapeutic procedures (therapeutic exercise, therapeutic activities, manual therapy, neuromuscular re-education), group therapy, supervised (untimed) modalities, active wound care management, etc.

When billing for Medicare, the CPT codes are EXTREMELY important and must be billed for correctly each session. For service based CPT codes, such as the evaluation or re-evaluation, hot/cold packs and unattended electrical stimulation, you bill one unit, no matter how much time is spent performing each of those. On the other hand, time-based CPT codes, such as therapeutic exercise, therapeutic activities, neuromuscular re-education, gait training, manual therapy, and attended modalities, such as ultrasound, must follow the 8-minute billing rule. Many of you probably learned the “8-minute rule” in school, but in case you need a refresher, here it is. In order to be reimbursed, from Medicare, for a time-based CPT code, you have to provide direct, hands-on, treatment for at least 8 minutes. Below is a quick reference chart to show how this rule applies for each timed code.

As was previously mentioned, the 8 minute rule only applies to time-based CPT codes, not service-based codes. This means if you provide a service-based code, such as unattended electrical stimulation, you can still bill for that code, on top of the other time-based codes, as long as the duration of that modality is 8 minutes or greater. Medicare billing is also based on total time so to make sure you are billing for the appropriate number of units each session, start by adding up your total timed and untimed treatment minutes and then reference the above chart to double check, prior to distributing units for each timed code.

Medicare billing guidelines and requirements are ever changing, so especially if you own your own clinic or practice, it is crucial that you stay up to date with Medicare’s billing requirements so that you continue receiving reimbursement for the therapy services you are providing. The next proposed Medicare change is expected to occur in January 2021 and will result in a 9% reimbursement cut for physical therapy services, if it passes. Billing can be difficult, especially when it comes to Medicare, but once you have billed for your services a few times, the process will become easier. One final thought…when in doubt, remember to start off by calculating your total treatment time (timed + untimed) and then follow the 8-minute rule!