Billing CPT Codes Physical Therapists Need to Know

Using the right CPT codes ensures your clinicians are being paid for their time spent with patients. And while providing exceptional patient care should be your primary concern, getting paid for that care is a close second. Billing insurance for physical therapy can be a tedious and time-consuming process. That’s why it’s crucial for PTs to have a strong understanding of how to bill both private insurance companies and Medicare for their services. 

Let’s examine the most common billing codes to use, which modifiers to add, billing for telehealth, and mistakes to avoid.

Physical Therapy CPT Codes

There are a lot of different codes a physical therapist can use when billing for their services. We’ll explain the 13 most commonly used ones. 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 the outpatient setting.

For services normally provided by PTs, there are 10 common codes. The descriptions for the services are ambiguous, which is why billing for your care can be such a tedious and difficult process. It’s unfortunate, but the language is left vague so if the insurance company doesn’t belive the service was medically necessary, they can more easily deny the claim. 

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 usually receives a higher reimbursement rate from insurance companies, because therapeutic activities take more skill and precision from the provider during the session. 

Timed vs. Untimed Codes for Medicare

Clinicians that bill Medicare can use two different types of codes: timed and untimed. When using untimed codes, the PT is paid a predetermined fee no matter how much time is spent with the patient. These untimed codes can be billed once per session. Timed codes are reimbursed based on time spent working 1:1 with their patient. Timed codes should only be used for skilled interventions and can be billed multiple times per session. 

These timed codes represent 15 minutes of treatment. But because treatment blocks don’t always fit into neat 15 minute segments, the 8-minute rule was implemented. In order to bill for one unit of time for a code, the provider must spend at least 8 minutes performing the service. To calculate the total units to bill for, add up the total minutes spent and divide by 15. If the remainder is more than 8, you can bill an additional unit.

Modifier Codes

Physical therapists can use modifier codes on insurance claims. A notorious modifier is Modifier 59. CMS defines modifier 59 as: “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.”

There are also “edit pairs;” services physical therapists commonly perform together. If you bill CPT codes that are part of one of these pairs, you’ll receive payment for just one of these codes. 

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. 

Billing for Telehealth Physical Therapy

Virtual physical therapy is becoming a more acceptable route for patient care and is an effective model of treatment. In the United States, each state maintains its own jurisdiction with respect to telehealth PT. It pays to look over state laws and regulations to bill appropriately for telehealth. 

Common Billing Mistakes 

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 is a common billing mistake as well. Insurance companies pay attention to which billing codes you use and how often you use them. If you use the same code too often, they may audit you. Vary codes correctly to avoid an audit and maximize your reimbursement. Many PT services can fall under therapeutic exercises, allowing for a higher reimbursement rate.