FAQ: How Are PT Services Billed?

Generally speaking, a physical therapist doesn't associate billing with treatment. To that point, many medical billers in rehab therapy would probably say that PTs are not the best at applying best practices for physical therapy billing codes. However, some billing know-how is required when physical therapy services are delivered and payment for services is required. 

Whether you’re a physical therapist looking to start a private practice or a seasoned veteran who just needs a refresher, you could use the answers to frequently asked questions (FAQs) to simplify the physical therapy billing process. So, without further ado, here are some common FAQs to answer the question, “How are PT services billed?”

What goes into the physical therapy billing process?

When it comes to insurance, there are no simple transactions for therapeutic services delivered. In order to get paid in full, you need to consult a volume full of billing codes to select the one that provides the most accurate and concise picture of the medical services provided—both for the insurance company and for health care reporting.  

What are ICD-10 Codes?

Every patient who receives physical therapy services (or occupational or speech therapies) needs to have an accurate medical and treatment diagnosis. That diagnosis is determined during a physical therapy evaluation. As a result of that evaluation, the provider will then document the patient’s condition using the International Classification of Diseases (ICD), which, as of October 2015, is ICD-10. The accuracy and specificity of the ICD-10 codes speak to the medical necessity of the services you plan to deliver. To help navigate this territory, the American Physical Therapy Association (APTA) created this shortcut list of ICD-10 categories.

If you’re ever in doubt as to whether your codes are reimbursable under your payer’s payment policy, call the payer before submitting the claim. In other words, in this case, it’s much better to ask for permission than for forgiveness.

What are CPT Codes?

Billing for physical therapy services requires reporting the services delivered. That reporting is done through the American Medical Association’s proprietary list of Current Procedural Terminology (CPT) codes. A CPT code is an alphanumeric code used by all healthcare practitioners to describe the type of treatment delivered, how long it took, and how many times the treatment was administered. These CPT codes are the backbone of how much a physical therapist can bill for services. 

How do CPT codes determine how much a physical therapist gets for treatment?

Each CPT code has a unique definition that can be referenced in the AMA’s CPT handbook. Therapists can save time by using medical billing software that is integrated with your EMR, like WebPT Billing and EMR. Either way, physical therapists are most often going to use the 97000 codes, and more specifically, movement intervention codes like 97110 (therapeutic exercise), 97112 (neuromuscular re-education), or 97530 (therapeutic activities). Other 97000 codes you might be familiar with include 97140 (manual therapy) or 97550 (physical performance test).

What is the 15-minute rule for physical therapy?

The 15-minute rule question is a common one asked on the internet—which illustrates the confusion many rehab therapists must work through when applying CPT codes for their treatment. There is no official 15-minute rule, but there is an 8-minute rule and rule of eights—which are two different rules, to be clear. That said, the rules factor in 15-minute increments that define how many units of a CPT code can be billed. 

By using the 8-minute rule or the rule of eights, physical therapists—or medical billers—can determine how many physical therapy billing units can be billed for a session of PT.

What is the National Correct Coding Initiative (NCCI)?

Now that we’ve covered more information about physical therapy billing units than you bargained for, let’s discuss the dreaded NCCI edits. These edits have plagued physical therapy billing practices—and most other medical billers—since they were introduced in 1996. Introduced to prevent improper coding and payments for Medicare Part B and Medicaid claims, the NCCI edit pairs dictate which codes can be billed together and which cannot. The list constantly changes, so the best option is to use a purpose-built EMR with all the correct coding regulations built seamlessly into your workflows. If you don’t use WebPT’s PXM platform, you can still stay up to date with NCCI edit lists and Medicare’s final rule.

What is the difference between Medicare patients and patients with commercial insurance?

Aside from the most obvious answer being age (at 65, every US citizen has Medicare in some form or another), there are also many regulatory differences between Medicare and a commercial insurance company. The majority of these differences come down to the ins and outs of how a physical therapist can treat patients and subsequently bill for treatment.  There are some similarites, though—like the credentialing process or basic medical billing processes. 

One thing to keep in mind about payer policies is that Medicare is often the leader in terms of how a service is covered and reimbursed—meaning if Medicare follows a particular rule, there’s a good chance insurance company ABC does, too. As always, if you are unsure of a rule or regulation, the best answer is always found at the source—so give your insurance representative a call.

What goes into the credentialing process?

For a physical therapy practice to bill a particular insurance company, their providers must be credentialed with that company.  Being credentialed by an insurance company allows you to become an in-network provider. Credentialing is vital to bringing in new patients since most patients choose a provider based on whether that practice accepts their insurance.  Some payers—like Medicare—do not allow non-credentialed providers to treat or collect payment from patients for any covered services. That said, getting credentialed isn’t exactly easy. You have to obtain:

• Malpractice insurance;
• An NPI;
• A physical clinic location; and
• A license to practice in your state.

If you have questions about the credentialing process, consider seeking the advice of a consultant or another PT with experience. They can help you complete the paperwork and assist you in getting accepted the first time around. For more information on the credentialing process, check out our blog post, “3 Common Rehab Therapy Credentialing Mistakes”.

Do I have to be in-network to treat Medicare patients or patients with commercial insurance coverage?

In short, the answer is no. You can be a non-participating provider with Medicare and an out-of-network provider with commercial insurance. There are many subtle rules and regulations that go into this distinction, so I suggest reading further on the subject. Lucky for you, WebPT’s blog has explainers on “Everything PTs Need to Know About Accepting Medicare Assignment” or “Billing for Cash-Based Physical Therapy Services.” And if you want to watch a webinar on an out-of-network physical therapy practice, we have that too.

What else goes into the physical therapy billing process?

I’ve discussed the brass tacks of billing for outpatient physical therapy services—but what about the back end of the billing process? I’m referring to what happens after the physical therapy evaluation and subsequent treatments have been completed. Well, to answer that let’s jump into the universal claim form and electronic data interchanges (EDI). 

What is a universal claim form?

The universal claim form is otherwise known as the CMS 1500 form. This doozy of a claims form is the basis for most all other forms of insurance claims physical therapy practices must submit to be paid for their services. Luckily, those forms are entirely electronic claim forms today — which is where the EDI comes into play. The EMR and billing software you use should auto-populate your claims forms for a smooth billing process.

Do you have more questions on how PT services are billed?

The physical therapy billing process is subject to constant change. Every year, new rules are introduced by Medicare, and to complicate things even more, commercial insurance payers announce rule changes on a whim (or so it would seem). No one can be aware of and guess every change to physical therapy billing on their own, so don’t try it. Instead, partner with software that promises to make your physical therapy billing process seamless by using a PXM platform that promises endless connectivity, clean claims, and rock-solid care delivery. In the meantime, you can always continue to read up on the latest news for physical therapy billing on the WebPT intelligence hub.