Physical therapy billing
Priority Health requires that all physical therapy and rehabilitation medicine documentation meet national and Medicare standards.
CMS 1500 form modifier requirements
As of Jan. 1, 2014, all therapy codes billed on the CMS 1500 form must use modifiers consistent with Medicare rules to distinguish the discipline of the plan of care. The GP modifier indicates services delivered under an outpatient physical therapy plan of care.
Medicare patients have an annual "cap" on therapy services
Under Medicare, no prior authorization is required. However, Medicare imposes an annual dollar limit or "cap" when services reach a dollar amount set annually by Congress.
Providers may bill beyond the annual dollar amount if it is determined that additional services are medically necessary. The provider must document medical necessity in the record and bill with a KX modifier.
Once services reach $3,700 (for PT/speech therapy combined, or for OT), a prospective review is required before additional therapy is offered, or claims may go to member or provider liability.
Learn more about the therapy "cap" and prospective reviews.
Copayments, coinsurance and deductibles
Use the Member Inquiry tool to look up a patient's benefits.
- Abbreviations unique to your office should be documented in a standard abbreviation sheet so that everyone in your office uses abbreviations in the same manner.
- Abbreviations should not be the only documentation when describing care such as: HP, STM, US, MSG, ROM, MT, and WNL. The documentation must also include a clear description of the treatment provided and how the patient tolerated the treatment.
- Documentation stating "treatment tol well" or "continued as above" is not acceptable medical record documentation reimbursable by Priority Health.
- All documentation should be legible.
- Provide a definition sheet of abbreviations specific to your office to assist us in interpreting your medical records.
- Documentation must match the plan of care/treatment.
- Documentation must support medical necessity of the treatment modality and procedure.
- When documenting, indicate how the patient tolerated the service, and/or what or why the patient was not able to perform the exercise as instructed.
- Each page of the medical record should include the member/patient's name and date of service.
- Documentation corrections should be a single line drawn through the error with the corrected text in close proximity, with initials and date corrected by the person who made the error.
- All documentation provided by a qualified health care professional should include a written or electronic signature, initials, and or stamp of original signature.
- Documentation must stand alone for each date of service.
- Priority Health acknowledges that providers may utilize their own format for documenting physical therapy services, however the documentation must support the services billed for each date of service
Evaluations and re-evaluations
- Evaluations should be comprehensive examinations which support the treatment plan and medical necessity of care. An initial examination and evaluation always should be performed for each episode of care.
- Re-evaluation is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. Indications for re-examination may include; change in the patient's condition that was not anticipated, new clinical findings or failure to respond to physical therapy intervention.
- A patient will be reassessed at each visit; however, reassessments are not re-evaluations, do not constitute a separate test procedure and should not be reimbursed separately from the procedure/s performed on that date of service.
Document supervised and unsupervised modalities to identify which services were provided. For example:
- Indicate that the service was supervised in the progress note for each date of service where this code is billed.
- It is also helpful to note the amount of time supervised; however, this is not a requirement.
- Supervised modalities require supervision from the provider, but direct one-on-one contact is not required.
- These services should be reported once per session, not per body area treated or per diagnosis treated.
Modalities which require constant attendance:
- Indicate in the notes only the actual time spent with the patient performing the service/procedure. If you spent any time out of the room or away from the patient, that time can not be billed as these codes require one-on-one direct contact.
- For example: Patient received treatment for 30 minutes, billable time of 15:
- 5 minutes with the patient starting therapy
- Therapist steps away for 10 minutes
- 5 minutes when therapist comes back and checks on patient
- Therapist leaves for 5 minutes
- 5 minutes when therapist returns to discontinue treatment
- Total billable direct patient contact is 15 minutes.
- Should indicate in the progress note that the service provided was unsupervised.
- Unsupervised gym time is not billable, although Priority Health recognizes that the patient may start some exercises in the gym without supervision.
- Example: If a patient has previously been instructed on floor exercises, the therapist may ask the patient to start with an exercise they have demonstrated the ability to perform while the therapist checks in with another patient. This unsupervised time is not billable.
Manual muscle testing (MMT) & range of motion (ROM)
These services are provided as part of an initial evaluation or re-evaluation. When performed in the same day as the evaluation service or for routine assessment when documenting the patient's expected progress in accordance with the plan of care, they are not separately reimbursable services.
- Documentation to support the use of these codes must include a formal, distinctly identifiable use and a dated, signed, written report of the findings.
- Each report must include testing of muscle strength and /or range of joint motion with comparison of values to a specific standardized grading scale.
- The written report must include the provider's findings incorporated into the therapy plan of care.
- These are un-timed codes and it is not appropriate to bill for more than 1 unit per treatment.
Therapeutic procedure descriptive notes should reflect code definition. Examples:
- Exercise performed: TE - 10 minutes on the treadmill at 5-degree incline for 15 minutes
- Time spent performing the exercise, documented in a number of ways:
- Total time spent
- Start and stop times
- Total time for each exercise to arrive to your total time
- An update on functional status (i.e. status regarding range of motion)
Time-based procedures and services
- Time-based codes are identified by the statement, " ...each 15 minutes." These codes are reported in 15-minute units of time spent providing skilled services.
- Direct one-on-one supervision is required to report time-based services.
- Codes are reported in units totaling the accumulated time, not per diagnosis or areas treated.
- Time is determined by a timetable that Centers for Medicare & Medicaid Services (CMS) established, which is recognized as the industry standard:
- Less than 8 minutes (<8 minutes) is not a billable service
- 1 unit = 8 to < 23 minutes
- 2 units = 23 to < 38 minutes
- 3 units = 38 to < 53 minutes
- 4 units = 53 to < 68 minutes
- Time spent in a waiting room or awaiting treatment should not be included.
- Time spent with the patient can be documented in a number of ways:
- Total time spent
- Start and stop times
- Totaled time for each exercise, to arrive at your total time for time-based procedures and services
Ultrasound and electrical stimulation
Billing for ultrasound and electrical stimulation requires documentation of:
Electrical stimulation can be an unattended and/or attended service:
- Unattended services do not require supervision and are not time-based. They are billed as one unit per treatment session. Documentation should still indicate duration/time and that the service was unattended.
- Attended services require constant supervision (direct one-on-one contact) and are billed in 15-minute increments.
Skilled gait training is required when billing this service. Therapists are expected to provide clear documentation of the skilled assessment of the patient's gait deviations/deficits to support therapeutic intervention/treatment.
- Incomplete documentation example:
- Walked patient 250 ft times 2
- Preferred documentation examples:
- Patient training included proper gait sequence, which required moderate assistance for balance and weight shift.
- Patient walked without shortness of breath or fatigue. Patient is still unable to walk step-over-step without railing.
Group therapy consists of two or more individuals under the provider's supervision.
- The individuals can perform either the same or different activities.
- Direct one-on-one contact is not required.
- The group therapy code is reported for each individual involved in the group session.
- This is not a time-based service.