Physical therapy coding and billing is often misunderstood. Our goal is to lay out appropriate and compliant billing practices in simple terms that will make your documentation, and coding, easy to understand.
Physical therapy billing and coding is very dynamic and our intent is to empower our PTs with updated billing best practices to improve billing accuracy and make a difference to the PT industry as a whole. Please feel free to reach out to us with any questions or queries.
1. Evaluation Codes
2. Treatment Codes
3. Medicare 8 Minute Rule vs SPM
4. KX Modifier for Medicare
1. Evaluation Codes
Untimed vs Timed Codes for Initial Visits
During an evaluation (Initial Visit), you will likely have to use two types of codes to fully reflect the service provided.
The first code will be an untimed code called “evaluation”. This code is untimed, which means that regardless of how long it takes (20 minutes, 30 minutes, etc.), you can only specify that one untimed code for the evaluation portion of the visit.
The second code you will likely use is called a timed treatment code. Don’t forget to always specify the additional treatment codes for the care you provide during an Initial Visit. This can include exercises, manual treatment, gait training, neuro re-ed, etc.
Physical therapists have three choices for evaluation codes for all payers: Low, Moderate and High Complexity.
Complexity is determined via a variety of factors and is indicated in the table below:
- Examination of body systems, including these elements:
- Body structures and functions - including psychological functions.
- Activity limitations: Difficulties an individual may have in executing a task, action, or activities (e.g., inability to perform tasks due to abnormal vital sign response to increased movement or activity).
- Participation restrictions: Problems an individual may experience in involvement in life situations (e.g., inability to engage in community social events due to exhaustion).
- Clinical presentation
- Clinical decision making
- Time spent during the evaluation is not necessarily indicative of the complexity
Example Scenario 1:
Maria is a 65-year-old recreational tennis player with a history of cervical disc degeneration and aching ongoing pain. She has been complaining of some neck and shoulder pain causing intermittent discomfort. She feels progressive increase in the discomfort level over the last couple of weeks. Maria complains of pain with turning her head to the L when driving, with lifting >5-7 lbs above shoulder level and also complains of pain with waking up in the morning especially on her left side sleeping. In the last couple of weeks, Maria’s pain has been shooting down the L shoulder and affects her backhand play in tennis. At its best, pain level is 0/10, but during and after playing tennis the pain level can rise to a 7/10. During evaluation, Spurling’s test is positive on L, Maria also demonstrates decreased biceps reflex and decreased sensation in C6 dermatome. ULTT test is positive for median nerve. Neck Disability Index score is 26/50 and has functional limitations with prolonged sitting, side sleeping, driving, lifting, and tennis moves.
Based on your evaluation, you would select which complexity evaluation code for Maria?
Considering that all the factors in the required components were met, a “Moderate” complexity sounds reasonable.
Example Scenario 2:
George is a 45-year-old University professor with a history of asthma and cardiac arrhythmias. He sustained an ACL injury while playing recreational soccer thus causing swelling, end range knee extension lag, difficulty weight-bearing, and walking. Patient saw MD for further testing, got diagnosed with complete ACL rupture and plans to undergo surgery in 2 weeks. George is referred to PT to improve knee extension ROM, quad activation and prehab.
In this scenario, even though several activity and participation restrictions are present, all the factors in other required components indicate Low complexity. Clinical presentation is stable with no significant change predicted. It is appropriate to bill “Low” evaluation complexity if all the required components do not indicate the higher complexity code.
Important takeaways from this section are:
- Bill timed treatment codes in addition to untimed evaluation codes for the Initial Visit.
- All payers require evaluation complexity codes as Low, Moderate and High complexity, based on the required components.
2. Treatment Codes
Most treatments are timed procedures reflecting a timed codes. Timed codes require at least 8 mins of care to allow billing a code. See below for the definitions of the timed codes we commonly use, and the supporting documentation needed.
All codes must show the skilled need for intervention by a therapist. Always code to the highest level of specificity.
Important: All skilled interventions must include level of assistance or cuing for performance of activity. Education is considered part of the active service you are providing, not as a separate code.