Physical Therapy Billing Live Q&A: John Wallace's Hauntingly Helpful Compliance Tips FAQ Recap

One of our favorite spooky season traditions here at WebPT is our annual live Q and A webinar featuring Heidi Jannenga, PT, DPT, ATC, Co-Founder and Chief Clinical Officer of WebPT, and John Wallace, PT, MS Senior Vice President, Member Value at WebPT. It’s a chance to have a little fun with the format and trot out a few Halloween-themed images and costumes; more importantly, it’s a chance for viewers to pose their most difficult questions to our hosts in real-time. Because billing and compliance can be such a tricky topic, we had far too many questions, even with almost 50 minutes devoted to our Q and A. As such, this particular FAQ is jam-packed, as we try to answer the outstanding questions with the assistance of John Wallace for the particularly complex scenarios. 

Medicare Billing Compliance

When Medicare is primary and a commercial is secondary, can we bill using the CPT Rule of 8s?

Rule of 8s requirements largely depend on the primary payer. In this instance, let’s assume traditional Medicare is primary. If so, you must follow the Rule of 8’s. If, however, there is a Medicare Advantage plan in effect, then you should consult with the specific plan to determine their rules.

If a patient has Medicare primary and Medicaid secondary and I am not contracted with that secondary and they won't pay, can I collect the remaining payment from the patient?

According to Wallace, “If you are OON with the secondary and you know they will not pay, you can collect from the patient. If you are not absolutely sure they won’t pay, you should wait until after the bill gets crossed over from Medicare to the secondary and wait for the ERA. You would have accepted the assignment, so if there are OON benefits, you will get paid.”

How many times in a year will Medicare allow you to bill an eval? How often can you bill an initial eval to Medicare for the same diagnosis per calendar year?

Medicare does not explicitly limit evaluations for the same diagnosis in a given year. Instead, “medical necessity” defines the coverage determinations Medicare enacts. This resource by CMS does an excellent job of summarizing medical necessity and multiple evaluations for the same diagnosis.

How do you bill two diagnoses and two different insurance providers? For example, how might we bill Medicare for treating a shoulder and worker’s comp for a foot?

In this instance, you should create two separate cases. There should be no issue in this specific case, as the payer sources are different.

Why are taxonomy codes being required by Medicare? 

“Taxonomy codes are linked to your NPI,” says Wallace. “This is another way for payers to verify your specialty and what adjudication policies apply to your specialty.”

Are Medicare Advantage plans and Tricare required to follow the exact same CMS Medicare guidelines?  

Medicare Advantage plans are required to follow the rules set forth for Medicare Part C by CMS, but they do not have to follow all Medicare Part B rules as they have their own policies.

Tricare will operate in much the same way, but—as with many insurance plans—there are differences. Check out this resource on Tricare’s website for more details.

Medicare Advantage/Secondary Insurances

A patient has a Medicare Advantage Plan as primary and Medicare as secondary. Can I bill Medicare for the remaining amount? Is Medicare ever secondary? 

Per Wallace, “This particular arrangement is not possible; if a patient has Medicare Advantage, they cannot have traditional Medicare as well.”

A patient has UHC Medicare Advantage as their primary insurance and Medicaid as their secondary and I'm not in network with Medicaid. Can I collect the copay if I’ve informed them up front? We have been billing dry needling as manual and haven’t run into any issues. 

“You can collect the copay up front if your state allows it through their share of cost program,” says Wallace. 

CPT Coding

Would rows with resistance bands and squats be billed as 97110 or 97530?

The answer to this question rests solely with the intent and goal of the specific intervention. For example, if you perform rows to build the strength of the rhomboids or related musculature, this would sit squarely with 97110 (therapeutic exercise). However, if your patient needs to perform a rowing motion to improve on a functional deficit—and your documentation supports this—then 97530 (therapeutic activities) would be a better choice. The same rationale applies to squats. For more information on movement intervention codes, check out Wallace’s blog blog post on the subject. 

Any advice when billing 95992 to the insurance companies? We understand it is not a CPT code that should be billed alone.

“Canalith repositioning can be billed by itself unless the payer has a medical policy stating otherwise — which is very rare,” says Wallace.

When is it appropriate to bill CPT code 97535?

According to the CPT code description, 97535 is intended for use with “activities of daily living [ADL] and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment.” While it’s generally used more as an OT code, it can fall within the PT scope of practice. However, be sure that these activities don’t overlap with those that might be billed as therapeutic activities under 97530.

Do you have any advice on billing 97129 and 97130 to avoid getting denied? 

Without more specific information on the reasons payers might cite in a hypothetical denial, it’s hard to give a definitive answer. According to this article from ASHA, you must complete at least eight minutes of face-to-face therapy to bill for 97129, which covers the first 15 minutes; to bill for 97130, you need to have completed the full 15 minutes of 97129 plus at least an additional eight minutes. To bill for an additional unit of 97130, you would need to complete the full 15 minutes of the first unit of 97130.  

When a therapist has a patient visit to go over a piece of new pediatric equipment that needs to be ordered, what CPT code would you bill for the therapist's time?

The applicable code would depend on the equipment; based upon that, you might classify it as therapeutic activity, self-care, or an equipment checkout.

Multiple Procedure Payment Reduction (MPPR)

Do the MPPR rules apply to hospital-based clinics (non-private practice)? 

“MPPR applies to all outpatient settings,” says Wallace. 

Evaluations

Is a group code or group sessions allowed for evaluations?

You can’t do group evaluations, but you can do group treatment on the day of the eval. If problems arise, the best action is to call the specific payer plan for further guidance. Individual codes can often prove more advantageous after an evaluation to account for the time you spend on education, self-care, or even implementing therapeutic exercises for a Home Exercise Program (HEP). 

If a client has been discharged but wants to return to care for the same issues after a gap of three to six months, would an eval or re-eval be more appropriate?

In this case, you should do a new evaluation, as this would start a new episode of care.

ICD 10 Coding

What ICD 10 code would you recommend I use for weakness? 

There are two specific codes that apply to weakness: M62.81, muscle weakness, generalized, and R53.1, weakness. M62.81 is perhaps the more common code seen in PT settings and is characterized by a reduction in the strength of muscles in multiple anatomic sites. R53.1, on the other hand, is a sign or symptom associated with:

• weakness and diminished or absent energy and strength;
• debility, or lack or loss of strength and energy;
• physical weakness, lack of strength and vitality, or a lack of concentration;
• lack of physical or mental strength;
• liability to failure under pressure, stress, or strain;
• weakness; and
• lack of energy and strength.

In the event either of these codes is denied by a payer, the best course of action is to call the specific payer and ascertain a specific reason for the denial and how they recommend going about billing the claim.

In-network vs. out-of-network

For out-of-network insurance, can we charge the patient directly for the full amount of services and allow them to submit for reimbursement independently, so long as we provide them with a "cost quote" before services and a superbill following service? 

“Yes, you can do that,” says Wallace. 

If we are out-of-network with a Medicare Advantage plan that offers out-of-network benefits, are we allowed to balance the bill with the patient for any payment adjustments applied by the payer? 

According to Wallace, “Yes, you can balance bill patients—as long as you do not exceed the Limiting Charges for the services you provide.”

Claim Denials

How do you handle Medicaid denial for authorization when the reason for denial is that the patient is over 21 years old and the condition is chronic?

Without knowing the specific state and Medicaid plan for this case, a specific answer is hard to determine. However, we often advocate that when dealing with Medicaid plans and payment for services, reaching out directly by phone to a representative from that office is the best course of action.

Supervision

Also, the direct and general supervision for assistants—is that for private practice only? I work in a hospital and hospital outpatient clinic in Texas and thought we just needed general supervision for PTAs. 

The rule changes for supervision guidelines were related to private practice; hospital settings will have different rules for general supervision.

Modifiers

If we utilize PTAs/OTAs, should we include the CO/CQ modifier for all carriers or just those that require it?

We recommend including CO/CQ modifiers only with those payers who require it. 

Do we have to use CQ/CO modifiers if we're a critical care hospital outpatient?

Per this reference from CMS, outpatient services of a critical access hospital (CAH) do not have to use the CQ/CO modifier.

Do you use the X{EPSU} codes for Medicare billing for inpatient and outpatient facilities?

Yes, you should use the X modifiers to provide creator specificity in your coding in situations where you previously would have used the 59 modifier. As a refresher, these are the X(EPSU) modifiers: 

• XE (Separate Encounter): A service that's distinct because it occurred during a separate encounter
• XS (Separate Structure): A service that's distinct because it was performed on a separate organ/structure
• XP (Separate Practitioner): A service that's distinct because it was performed by a different practitioner
• XU (Unusual Non-Overlapping Service): A service that's distinct because it doesn't overlap the usual components of the main service

What is the fastest way to get reimbursed for a patient coming in for OT and PT on the same day if the payer only acknowledges one discipline? Is there a modifier that we should be using? 

Wallace clarifies, “Use the GO and GP modifiers for the OT and PT services as appropriate. Use the 76 modifier on any CPT codes used by the first treating provider that day.”

New Parkinson’s Disease Codes

Can we see Medicare patients for therapy in the home and bill under place of service code 12? We have Parkinson's patients whose symptoms flare up and can't attend therapy in the clinic. 

According to Wallace, “You can see patients in the Office (POS 11) or the Patient’s Home (POS 12).”

Is the PD diagnosis code a medical diagnosis code or a therapeutic code? I have had prompts to change it in WebPT but I am not sure if I need to get a new prescription from the MD. 

The new Parkinson’s Disease Diagnostic Codes are in fact diagnosis codes, and you should be using the new, more specific codes for all services on or after October 1, 2023.

RTM Codes

What if we are not billing RTM/RPM codes in a private outpatient clinic? Are they required?

No, RTM isn’t required for use with patients—but it is a good tool for improving outcomes with better feedback on adherence and response to treatment. If you are looking for some use cases and practical examples of RTM in a PT clinic check out this blog post.

Dry Needling

Any tips on not getting denied for extracorporeal shockwave therapy (ESWT) and dry needling treatments?

Getting payment for these two services will largely depend on the specific payer. For example, Medicare does not cover the CPT codes for dry needling at this time, so an ABN would need to be issued, a GX modifier applied to the claim, and the patient would have to pay out of pocket. Some practices have opted to bill dry needling as manual therapy or neuromuscular re-education, but be forewarned that if an audit were to occur, this might welcome increased scrutiny as a form of treatment bundling—which is a recognized form of billing fraud.

Can an aide remove dry needles from a patient? If yes, should the PT be supervising or have a line of sight while doing so?

The answer to this question rests with your state’s practice act for PTs, PTAs, and aides. Beyond this, as dry needling is a relatively new treatment option for physical therapy practice and not clearly defined by some practice acts, the use of an aide for anything to do with dry needling could open the door to legal and regulatory scrutiny your clinic and fellow PTs do not want.

Credentialing

Can you get paid when a new therapist has not been approved and credentialed yet but seeing patients?

Hold those claims then submit them once the therapist has been credentialed. Medicare will pay back to the date of the 855 application. Commercial payers do not usually cover retroactively from the date of approval.

What are the supervision rules for a fully licensed therapist without Medicare credentials? Is cosigning allowed for outpatients? 

We recommend holding claims until you get their enrollment letter. 

When you use traveling therapists, how do you credential them? 

Per Wallace, “You would credential them just like any other therapist.”

Third-Party Insurances

We have had a few insurance companies request refunds of overpayment due to them updating the fee schedule; however, we have been billing the same charges under our rate with the same amount for the past few years. Is there a way to dispute this? 

Many states have a one-year window for payers to request refunds for overpayment, although the payer should have to provide a written explanation for why they’re seeking overpayment. That said, your contract with a payer should clearly outline how to start the process of disputing these refunds as well as how disputes are adjudicated. 

Is there any recourse against third-party worker’s comp companies when they don’t pay a claim? 

“State workers compensation laws and regulations set these types of rules,” says Wallace. “Check with your state’s Workers’ Comp Department about seeking payment arbitration and/or filing a lien with the payer on your case.”

What happens when you do a verification of benefits and they tell you no prior authorization is required but then process the claim and deny for no authorization? They say our only option is to try for a retro-auth, which I doubt they will approve. If an appeal continues to be denied, are we able to bill the patient if the contract says we can’t? 

“In this case, you should engage the dispute resolution path set forth in your contract/agreement with the payer,” Wallace states. 

UHC rescinded payments from us for claims in 2022 for lack of start/stop time. We were never given the option to send schedules. We have appealed but those have been denied. Can we do anything since this rule supposedly started in August? 

Wallace reiterates, “This is another instance where you should avail yourself of the dispute resolution mechanism in your contract/agreement with that payer.”

Our clearinghouse only sends the CMS 1500 form.  We don't attach chart notes. Will UHC reject our claims because we don't have the treatment times on the CMS 1500? Is there a way to include the times? 

“The start/stop times go on the visit documentation, not the billing format. They are only reviewed by the payer if they audit the claim,” Wallace clarifies. 

If we are OON with UHC, will we need to document the treatment times?

As Wallace notes, “If you’re out of network, UHC can’t compel you to comply with their requirements for documenting start/stop times — but they do have the option to seek repayment from a patient upon audit if the start/stop times aren’t included.” 

Do Aetna’s de minimis rules apply to inpatient and/or outpatient environments? Is there an exception for inpatients and/or at critical access hospitals? 

“The de minimis rules only apply to outpatient settings,” says Wallace.

Do you have any advice for what to bill when a patient returns with a different or the same issue within six months with Aetna? They only pay on one eval code every six months, and re-eval codes are included in that. 

“That is a provision of Aetna’s medical policy,” Wallace notes. “You need to bill the re-eval codes to be in compliance with the Aetna policy.”

As you can see, the billing and compliance questions never end—especially when CMS and commercial payers are constantly changing the rules. In the meantime, we’ll be here to provide as much clarity as we can. If you’re itching for more answers about billing, WebPT Members can check out John Wallace’s monthly Billing and Compliance Bootcamp webinars where he discusses some of the trickier topics we covered above; keep an eye on your emails for registration details, or email billingquestions@webpt.com for more information.