What physical therapy clinics need to know about CPT modifiers

Current Procedural Terminology (CPT) codes are used to identify the type of service or procedure that is being billed for. They are used in health care settings and by insurance providers to determine reimbursement rates.

Just as important are CPT modifiers. What do these supplemental codes do, and why do they matter to physical therapists? Keep reading to find out.

What are CPT modifiers?

CPT modifiers are used to add supplemental or explanatory information to CPT codes. Instead of simply using a CPT code that lets the insurance company know which services were performed, CPT modifiers are used to add context to each code.

For instance, if a patient was coached through therapeutic exercises during their session, you would use the CPT code 97110. If that session took place virtually as a telehealth appointment, you would add the CPT modifier -95. This is important information to add because the patient’s insurer may or may not cover telehealth treatment.

Which CPT modifiers are used in physical therapy?

Here’s a list of some modifiers commonly used in the physical therapy industry:

• -22 — This modifier denotes increased procedural services. It should be used when the labor required to treat a patient is significantly greater than typically necessary. This signifies to insurers that you believe the additional time used in treatment was medically necessary and that they should therefore provide coverage to the patient.
• -52 — This modifier denotes reduced services. It should be used when you reduce a service or procedure, resulting in a shorter treatment. Thus, the treatment may not be billed to the extent that it normally would.
• -59 — This modifier is used in cases where two distinct procedures are performed on the same day. It lets insurers know that the two procedures are to be billed separately. 
• -95 — This modifier denotes synchronous telehealth treatment. It can be used as a CPT modifier for most services that can be performed virtually. You should note that this modifier pertains only to synchronous telehealth treatment, meaning a virtual interaction between you and your patient that takes place in real time. Also, the services performed must contain the same components as an in-person session, and the session should last the same amount of time as a typical in-person visit.
• -96 — This modifier denotes habilitative services. In other words, it is used when your physical therapy services help the patient with skills for daily living. These skills may be entirely new to the patient, or you might be helping them improve or retain their skills.
• -97 — This modifier denotes rehabilitative services. When you perform rehabilitative services, you help your client regain skills that they’ve lost due to an injury, illness or ailment. 

What about HCPCS modifiers?

The Healthcare Common Procedure Coding System (HCPCS) is another coding system, separate from CPT. It is often used for Medicare patients. HCPCS has its own set of codes to describe services and its own set of modifiers to provide supplemental information.

Here are a few examples of modifiers commonly used by physical therapy clinics:

• GP — Used in institutions, such as hospitals, where it could be unclear which type of professional performed the service. For instance, a physical therapist might use this if the service could have been performed by another type of medical specialist.
• GX — This modifier is used when patients wish to continue receiving physical therapy services even after it’s no longer medically necessary. Maintenance therapy is not typically covered by insurers, so the GX modifier enables you to bill secondary insurers or the patient themselves.
• KX — This modifier is used when a Medicare-covered patient exceeds Medicare’s threshold for physical therapy therapy services. It is a way to let the insurer know that you’ve deemed the patient’s treatment to be medically necessary and are therefore requesting for them to cover it.

AgileEMR systems can help you use the right modifiers

AgileEMR automates the process of adding modifiers to your billing codes. It has a built-in rules engine designed to determine the correct modifiers for the situation. In addition, our EMR system features a wide range of helpful tools for documentation, task management, scheduling, reporting and more. We can help you to streamline all of your clinic’s administrative tasks so you have more time to focus on the other aspects of your business.

Contact our team today for more information or to schedule a demo to see how AgileEMR can help your practice.