Code This, Not That: How to Maximize Your PT Billing by Using the Right CPT Codes

Physical therapy billing is equal parts art and science. On one hand, we want our codes to accurately represent the services we have provided, but on the other, we want to generate maximum reimbursement—while avoiding the risk of fraudulent billing.

While compliance experts might be able to code like ninjas without breaking a sweat, the rest of us often struggle to walk the billing and coding line. Using CPT codes to their fullest is a great first step toward overcoming that challenge.

The main thing to keep in mind is that your CPT codes should always match the intent of the physical therapy interventions described in your notes.

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Obviously, that means that the more detailed your note, the more likely it is that you can bill a code with a higher reimbursement rate—because auditors will understand your therapeutic rationale. But, a detailed note alone does not always justify a higher-paying code.

When you’re billing for gait training (97116), mechanical traction (97012), or manual therapy (97140), the therapeutic intent is pretty cut and dried. However, the movement intervention codes (think 97110, 97112, and 97530) are a bit trickier. With that in mind, let’s walk through a few examples.

Examples of How to Maximize Your Billing

Example 1: Open-chain right shoulder exercises; 3x10 with eyes closed. Manual cues provided to facilitate proper scapulohumeral rhythm and position sense.  

Code this: 97112 (neuromuscular re-education): Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture and/or proprioception

Not that: 97110 (therapeutic exercise): Therapeutic exercise to develop strength, endurance, range of motion and flexibility

Here, many of us would assume that the open-chain, active nature of the exercises means we should bill the time under therapeutic exercise. However, the manual cues and eye closure do provide neuromuscular re-education, which means we can bill that code with confidence.

Example 2: Floor to waist to shoulder-level lifting of 15-pound 2' x 2' box to simulate picking up patient's 1-year-old grandchild.

Code this: 97530 (therapeutic activities): Therapeutic activities (dynamic activities to improve functional performance)

Not that: 97110 (therapeutic exercise): Therapeutic exercise to develop strength, endurance, range of motion and flexibility

As in the first example, the temptation here is to assume that lifting a weighted box constitutes therapeutic exercise. And it does—unless you specifically document that the motion simulates picking up a patient’s grandchild, as this brings functional performance into play.

Example 3: Left ankle dorsiflexion, plantar flexion, and eversion exercises with blue resistance band in a seated position 2x10 to increase anterior, posterior, and lateral calf strength and stability for the ankle in order to improve running tolerance.

Code this: 97110 (therapeutic exercise): Therapeutic exercise to develop strength, endurance, range of motion and flexibility

Not that: 97530 (therapeutic activities): Therapeutic activities (dynamic activities to improve functional performance)

In this example, you may assume that building strength and stability in the ankle means that the patient is performing a therapeutic activity, because he or she is improving running tolerance. However, the activity itself is not simulating any aspect of running, and therefore would be considered therapeutic exercise.  

Example 4: A patient you’ve been treating for right shoulder impingement complains of low back pain (LBP). She asks you to address her back pain at today’s visit.  

Code this: Eval (97161, 97162, or 97163, tiered depending on the complexity of the evaluation)

Not that: Re-eval (97164, not tiered depending on complexity)

In the above example, you must bill a new evaluation code, rather than billing for a re-eval. In the past (meaning prior to the introduction of tiered codes), the re-evaluation code could be used to add a new, unrelated problem to an existing plan of care (POC). In the example above, that’d mean that even though your original plan of care was for the right shoulder, you could add LBP to the plan, too.

Nowadays, the re-evaluation code can only be used to revise the POC for issues related to the original problem, so if, in the example above, you’re updating the POC to include LBP, you’ll need to bill another evaluation code.

In the world of billing, the only constant is change, so it’s vital to stay on top of documentation requirements. That way, you’ll be sure to stay compliant, provide written evidence of the stellar care you provide, and generate the maximum amount of income from each session.