The Complete PT Billing FAQ

Introduction

Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.)

WebPT

How does WebPT help me bill better?

WebPT prompts users to apply modifier 59.

When WebPT detects that you have billed two codes that form a CCI edit pair, the system will alert you and ask whether you performed these services separately and distinctly of one another—and, therefore, should receive payment for both. If you attest that this is the case, WebPT will automatically apply modifier 59 to the appropriate code.

For WebPT Members

To activate this feature, please follow the steps below. Note that you’ll need to complete these steps for each insurance plan. We recommend applying this to commercial and government plans only (i.e. no workman’s compensation, legal/lien, and auto liability policies).

1. Select “Display Insurance,” located on the left side of the WebPT Dashboard.
2. Click “Edit” on the individual insurance for which you want to activate the feature.
3. Once the insurance editing screen opens, check “Apply CCI edits”; then, select “Save.”

For Non-WebPT Members

If you’re not yet a WebPT Member, you can see this functionality and an array of other awesome features in a free, live online demonstration. Request your free demo here.

WebPT tracks the therapy cap.

WebPT offers the Medicare Cap Report, which enables you to view Medicare beneficiaries’ progress toward the therapy cap and see whether therapists have affixed the KX modifier for those patients who have, in fact, exceeded the cap. In addition to tracking the therapy cap, WebPT alerts providers when a patient is:

• approaching the cap
• exceeding the cap (time to attach the KX modifier!)
• approaching the manual medical review threshold ($3,700)
• exceeding the manual medical review threshold

To learn more about the Medicare Cap Report and WebPT’s other compliance reporting and tracking capabilities, check out this blog post.

WebPT calculates the 8-minute rule.

As this blog post explains, “WebPT automatically double-checks your work for you and alerts you if something doesn’t add up correctly. All you have to do is record the time you spend on each modality as you go through your normal documentation process, along with the number of units you wish to bill. If those two totals don’t jibe, WebPT will not only let you know something’s off, but we’ll also tell you whether you over-billed or under-billed. That way, you can quickly identify and fix the problem—and thus, ensure accurate payment. Plus, you’ll have a detailed record of the services you provided on each date of service—something many local MAC auditors request to substantiate billing claims and processes.”

WebPT handles PQRS reporting.

WebPT is a certified PQRS registry. This means we collect PQRS claims data and submit it to Medicare on your behalf. We also have all the PQRS reporting requirements in our system, so depending on the Medicare beneficiary and visit, we’ll prompt you to complete the appropriate measure. Learn more about PQRS with WebPT.

What diagnosis code flows over from WebPT into my billing?

When you use WebPT, your treatment diagnosis is the one that is billed—not the medical diagnosis.

Modifiers 59

What is modifier 59?

Modifier 59 comes into play in the therapy setting when you provide two wholly separate and distinct services during the same treatment period. The National Correct Coding Initiative (NCCI) has identified procedures that therapists commonly perform together and labeled these “edit pairs.” Thus, if you bill two CPT codes that form one of these pairs, you’ll receive payment for only one of the codes—unless you provided these linked services separately and independently from one another and applied modifier 59 to one of the codes. As Brooke Andrus explains, “when you append modifier 59 to one of the CPT codes in an edit pair, it signals to the payer that you provided both services in the pair separately and independently of one another—meaning that you also should receive separate payment for each procedure.” You can learn more about modifier 59—and download your own modifier 59 decision chart and CCI edit pair chart. (Please note that modifier 59 is not exclusive to Medicare; most—if not all—third-party payers require this modifier.)

How should we document to support the use of modifier 59?

To ensure you are protected in the event of an audit, we recommend documenting in a way that clearly supports your billing. So, if you use modifier 59 to indicate that you provided two linked services wholly separate and independent of one another, your documentation should back that up. It might seem intuitive to you to provide certain services separately, but Medicare has linked them for a reason, and if you do not provide adequate proof that you are justified in “breaking” that link, you leave yourself vulnerable to claim denials and penalties.

What is an NCCI edit pair?

The National Correct Coding Initiative (NCCI) has identified procedures that therapists commonly perform together and labeled these “edit pairs.” Thus, if you bill a CPT code that is linked to one of these pairs, you’ll receive payment for only one of the codes—unless you provided these linked services separately and independently from one another and you applied modifier 59. You can learn more about edit pairs—and download your own CCI Edit Chart—here.

What about codes 97140, 97112, and 97110? These are common codes for our practice—can we use modifier 59 on any of them?

To determine whether the use of modifier 59 is appropriate, you first need to determine whether any of any of the codes you are billing form edit pairs, which you can do in our CPT codes guide. In this particular case, none of the codes form edit pairs; thus, use of modifier 59 would not be appropriate. However, if the codes you are billing do, in fact, form one or more edit pairs, then you may be able to use modifier 59 and bill for reimbursement of all codes. The key is ensuring that the manner in which you provided the services justifies use of modifier 59.

If 97012 and 97140 are billed for same date of service, does modifier 59 pair with 97140 or 97012? How about codes 97140 and 97530 or 97140 and 97142? Or 97530 and 97110?

For all questions about specific codes and pairs, please refer to the CPT code chart. If your codes form an edit pair and the manner in which you provided the services justifies the use of modifier 59, you’ll affix it to the secondary code listed in column 2.

Will Medicare reimburse us for manual and group therapy performed at the same visit?

According to the chart, cpt codes 97150 (group therapeutic procedures) and 97140 (manual therapy) are edit pairs. So, as long as the manner in which you provided the services justifies use of modifier 59, you may affix it to request reimbursement for both services.

I’m correctly applying modifier 59 to an edit pair. Why am I still not receiving payment for both services—or receiving a denial?

The CCI edit list we published is from Medicare. Most government payers—like Medicare, Tricare, and Medicaid—use this same list. However, some private payers create their own edit pairs; therefore, there is no guarantee they will pay for both codes in an edit pair, even with an applied modifier 59. For specific questions regarding an individual payer, please contact the payer directly.

How do we handle the fact that our system is making it difficult for us to correctly apply modifier 59? For example, it requires us to always—or never—apply it to each code.

If your system is making it difficult for you to correctly bill—and therefore receive the money that is rightfully yours—it’s time to speak up. Call the company directly to point out that the system is preventing you from adhering to payer guidelines, and explain how you’d like the system to work. Then, consider implementing a solution that’s better suited to rehab therapy billing and has already accounted for proper modifier use.

Other Modifiers

Should we be using X{EPSU}?

Last year, CMS issued four HCPCS modifiers—called the X{EPSU} modifiers—to “define specific subsets” of the 59 modifier.

1. XE – Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
2. XS – Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure
3. XP – Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner
4. XU – Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service

According to the APTA, these modifiers are not currently in use within rehab therapy.

What are GP, GO, and GN?

GP, GO, and GN are therapy modifiers that designate the type of therapy being provided (PT, OT, or SLP, respectively). When completing functional limitation reporting (FLR), therapists must report G-codes, severity modifiers, and therapy modifiers. Additionally, many payers require use of a therapy modifier when billing a designated therapy code.

How about GA?

The GA modifier indicates that a required ABN is on file because the therapist has provided a Medicare patient with a service or item that is not considered reasonable and medically necessary. When you use the GA modifier, you still must submit the claim to Medicare; you’ll then receive a denial with the claim adjustment reason code 50. At that point, you can bill the patient or his or her secondary insurance for any services not covered by Medicare.

And GX?

The GX modifier indicates that a voluntary ABN was issued for non-covered services. It also prompts an automatic rejection from Medicare. Please note that while Medicare systems recognize and allow the GX modifier on claims, Medicare will return the claim if the GX modifier is used on any line reporting covered charges. The GX modifier can be combined with modifiers GY and TS (to indicate beneficiary liability) but not EY, GA, GL, GZ, KB, QL, or TQ.

• TS = Follow-up service
• EY = No doctor’s order on file
• GL = Medically unnecessary upgrade provided instead of non-upgraded item; no charge and no ABN
• GZ = Item or service expected to be denied as not reasonable and necessary
• KB = Beneficiary requested upgrade for ABN; more than four modifiers identified on claim
• QL = Patient pronounced dead after ambulance is called
• TQ = Basic life support transport by a volunteer ambulance provider

To learn more about rehab therapy modifiers, download our Modifier Open Forum slide deck.

When should I use the KX modifier?

As the APTA explains, providers should affix the KX modifier “to the therapy procedure code that is subject to the cap limits only when a beneficiary qualifies for a therapy cap exception. By attaching the KX modifier, the provider is attesting that the services billed:

1. Qualified for the cap exception;
2. Are reasonable and necessary services that require the skills of a therapist; and
3. Are justified by appropriate documentation in the medical record.”

If you—and your patient—wish to continue treatment even though you do not believe that your services are medically necessary, you’d have to proceed on a cash-basis, in which case you’d need to collect an advance beneficiary notice of noncoverage (ABN) and apply the GA modifier to the claim. Please note that if you have an ABN on file, you should stop using the KX modifier on future claims for that patient.

After how many visits should I attach the KX modifier?

The therapy cap limits for 2016 are $1,960 for occupational therapy and $1,960 for physical therapy (PT) and speech-language pathology (SLP) services combined. Thus, the point at which you should begin attaching the KX modifier is determined by the dollar amount of services accrued as opposed to a specific visit number.

It is important to ask new patients if they have received any therapy services at any time during the year, as all PT, OT, and SLP services will apply to their cap. To determine how close the patient is to reaching the cap, you can safely assume $80 to $100 per visit. Additionally, you can access this information through CMS in one of two ways:

1. You can electronically view dollar amounts accrued toward the therapy limits on the ELGA or ELGB screens within the CWF (Common Working File) or on the HIQA screen for those providers who bill through fiscal intermediaries.
2. You can contact your Medicare contractor directly and request information regarding therapy services provided to a particular beneficiary. The amount accrued toward the financial limit is based on claim received date rather than the date of service.

What is a manual medical review?

Medicare beneficiaries who exceed the therapy cap are subject to a manual medical review to determine whether continued services are actually medically necessary. Earlier this year, the Medicare Access and CHIP Reauthorization Act of 2015 modified the manual medical review requirements so that the Supplemental Medical Review Contractor (SMRC) will select claims for review on a post-payment basis. SMRC will pay particular attention to:

• providers who have a high percentage of patients receiving therapy beyond the threshold (compared to their peers), and
• physical therapists, speech language pathologists, and occupational therapists who provide therapy in skilled nursing facilities, private practices, and other outpatient facilities.

CMS notes that “of particular interest in this medical review process will be the evaluation of the number of units/hours of therapy provided in a day.”

Coding

I thought you were never supposed to bill 97002. Is that not correct?

Billing for a re-evaluation is not the same as billing for a progress note. Furthermore, therapists should never bill a 97002 for a routine progress note, because, when you do bill 97002, you’re indicating that your patient’s plan of care has significantly changed. In fact, Dr. Heidi Jannenga explains in one of her founder letters that “you should only bill for a re-evaluation if one of the following situations apply:

• Through your own clinical assessment, you note a significant improvement, decline, or change in the patient’s condition or functional status that was not anticipated in the POC for that interval.
• You uncover new clinical findings during the course of treatment that are somewhat related to the original treating condition (i.e., a new diagnosis to add to the POC).
• The patient fails to respond to the treatment outlined in the current POC, and you determine that a change to the POC is necessary.
• You treat a patient with a chronic condition and you don’t see him or her for treatment very often.
• Your state practice act requires re-evaluations at specific time intervals.”

If you’re billing 97002—and it’s justified—but you’re still receiving denials, then you may need to affix the 59 modifier. When you perform re-evaluations on the same day that you provide other services, you must use modifier 59 to indicate that the evaluation was a separate and distinct service from the other treatment.

How do I bill for PT and OT on the same day?

First, be sure to review your payer contracts to ensure that:

1. The payers will reimburse for different service types on the same day, and
2. You understand what their guidelines are for doing so.

Second, be sure that you’re performing these services because you actually believe that it is what’s best for the patient—not because it’s logistically convenient. Medicare does allow this practice. However, there are rules that govern how you provide—and bill—for such services, and they differ depending on whether you’re billing Part A or Part B.

Finally, note that if the PT and OT provided the services to the patient at the same time (i.e., they were working as a team), then they cannot bill separately for those services. (For more on billing for co-treatment or team therapy, check out item 4 in this CMS resource.)

As far as how modifier 59 applies to billing for services provided at different times by therapists of different disciplines, the author of this article has this to say: “For example, if PT provided gait training (97116) and OT provided therapeutic activity (97530), the billing claim would need Modifier 59 on the 97116 charge to allow for payment of both codes, otherwise, the NCCI edit would only allow payment for 1 code. Since PT and OT were provided at separate and distinct times, Modifier 59 is appropriate.”

When do I bill for group therapy?

According to CMS, “Group therapy consists of simultaneous treatment to two or more patients who may or may not be doing the same activities. If the therapist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, it is appropriate to bill each patient one unit of group therapy.” That means, to bill for Group Therapy Services (code 97150), you need to have been in constant attendance of two or more patients; however, one-on-one patient contact was not necessary.

What code should I use to bill for dry needling?

Different payers may have different preferences when it comes to billing for dry needling. That said, as Lauren Milligan writes in this blog post, “if a payer doesn’t have a policy and/or preferred code, never use CPT code 97140 when billing for dry needling. Instead, the APTA advises that you ‘report the service using the appropriate unlisted physical medicine/rehabilitation service or procedure code 97799.’”

How should I bill for a home visit?

According to this resource from PT compliance expert Rick Gawenda, therapists may use the CPT code 97535 (self care/home management training) to bill for home visits, “assuming the therapist is working on the tasks that would justify the use of this code.”

How does one bill for physical performance testing?

According to this Coding Ahead article, it may be reasonable and medically necessary to conduct physical performance testing (CPT code 97750) for patients with neurological or musculoskeletal conditions “when there is a need to evaluate [their] ability to perform specific tasks.” Physical performance testing “may include a number of multi-varied tests and measurements of physical performance.”

Please note that this type of service should not be used “in lieu of evaluation or re-evaluation services...,” and “it is not medically reasonable and necessary to bill this service as part of a routine assessment/evaluation of rehabilitation services (97001, 97002, 97003, or 97004.)” You also should not report this code in conjunction with code series 95831-95834 or 95851-95852. In order to receive reimbursement for this service, “direct one-on-one patient contact is required.”

How do I determine the charge sent to an insurance company for a specific service code?

The charge amount associated with each billed code is determined by your contract with that specific payer. Payment rates are outlined in each insurance company’s fee schedule. If you have questions about charge and payment rates for a particular payer, we recommend contacting that payer directly. For information about the Medicare fee schedule, check out this page.

Where can I learn more about place of service codes and errors?

CMS provides a list of service codes and descriptions. You can learn more about service code errors or by typing “place of service code errors” into your search bar.

When should we use aftercare codes?

Therapists should only use ICD-10 aftercare codes to express patient diagnoses in a very select set of circumstances. To learn when it’s appropriate to use aftercare codes, read our post on using z codes for aftercare.

How do I know if an insurance over paid?

You should be checking all funds actually collected—versus the expected amount—based on your fee schedule with each insurance company. That way, you’ll know if the amount you received is either too high or too low—and you can take immediate action to remedy it.

ICD-10

What Medicare program is stopping in October?

Medicare will end the ICD-10 grace period on October 1, 2016—which means providers will need to choose the most specific ICD-10 code available or risk facing denials. You can learn more here.

How can we find out if our ICD-10 code selection is impacting our reimbursement?

When ICD-10 went into effect last October, CMS instituted a year-long grace period in which it would not deny claims due to lack of specificity. Therefore, you probably haven’t received a whole lot of denials thus far due to ICD-10 codes. However, that grace period will end on October 1, 2016, which means it’s imperative you use this time to ensure you—and your staff—understand ICD-10 as well as how to identify and use the most specific codes available. To learn more about how to use the information you have right now to avoid denials come October, read this post (or download it in handy checklist form here).

Advance Beneficiary Notice (ABN) of Noncoverage

Should I have an ABN on file for every Medicare patient, just in case?

No; Medicare strictly forbids providers from issuing “blanket” ABNs to ensure payment no matter what. In fact, issuing ABNs on a regular, routine basis could throw up a red flag to Medicare and make your practice more vulnerable to an audit.

Okay, then how do I know when to issue an ABN?

As explained in this blog post, “Effective January 3, 2013, providers must issue a valid ABN to collect out-of-pocket payment from Medicare beneficiaries for services above the therapy cap that Medicare deems not reasonable and necessary.” (Confused as to what Medicare considers reasonable and necessary? Check out our post to learn more about Medicare’s definition of medical necessity.)

So, let’s say you’re treating a patient who is about to exceed the cap, and you believe treatment beyond the cap is not medically necessary. If the patient wishes to continue therapy—and he or she is willing to accept financial responsibility in the event that Medicare or a secondary insurance does not cover the services—then the patient can sign an ABN, and you can continue providing treatment.

If you wish to provide non-covered services (i.e., services that Medicare never covers) to a Medicare patient, you don’t necessarily have to issue an ABN, but you can issue what’s known as a voluntary ABN as a courtesy to the patient. As Dr. Jarod Carter writes in this post, “When providing services that are never covered by Medicare, it is not mandated you provide beneficiaries with ABNs for these services, but you can certainly create your own written notice to inform them of what they’ll be receiving, what it will cost, and the fact that Medicare will not cover any part of those costs.”

What is the process for billing Medicare in conjunction with ABNs? Do we—or do we not—bill Medicare when we have an ABN on file?

Even if you have a signed ABN on file, you still must submit a claim to Medicare with the appropriate modifier and G-codes (when appropriate)—except in the case of non-covered services (i.e., services that Medicare never covers), in which case you may issue a voluntary ABN, but you don't need to submit a claim to Medicare. Once Medicare denies the claim, you may bill the patient for payment.

Should I use ABNs for Medicare Advantage beneficiaries?

Per this resource, “ABNs only apply if you have Original Medicare, not if you are in a Medicare Advantage private health plan.”

Claims

What are the most common reasons for claim denials?

According to WebPT president Heidi Jannenga, the most common reasons for claim denials include failing to verify insurance coverage—especially prior authorization—and entering incorrect information, such as denoting the husband as the principal beneficiary when he is actually on his wife’s plan.

How far back can I address a denied claim?

This depends on the payer. To determine how much time you have to address a denied claim, review your payer contract or contact the payer directly.

What is a clean claim?

A clean claim is one that is complete, accurate, and error-free. In other words, there would be no reason for a payer to deny the claim.

Contracts and Fee Schedules

How do we negotiate our payer contracts—even big insurance companies that don’t want to budge?

Negotiating payer contracts can be challenging, especially when you’re dealing with insurers that aren’t willing to budge. Ultimately, your goal is to arrive at a solution that works for your clinic—and the payer. WebPT’s Brooke Andrus wrote a comprehensive two-part series about negotiating payer contracts. You can find part one (making a plan) and part two (taking action).

Where can we locate our Medicare contracts?

Given that these contracts are legally binding documents that you have agreed to uphold, you should always keep a copy on file in a safe place. If you cannot locate yours, reach out to your MAC immediately to request a copy.

Is there an industry-standard fee schedule?

Medicare’s fee schedule is the most frequently referenced fee schedule. However, if you’re negotiating with payers other than Medicare, shoot for rates that are more than 100% of what Medicare pays.

Is there a process by which I can request a private insurance company pay for more visits than a patient's policy allows?

Most payers have an appeals process you can complete to request more visits. However, Dr. Heidi Jannenga warns, "it's usually futile." Unless there are extenuating—and "grave"—circumstances, payers typically adhere to their policies about the number of visits they're willing to cover; very rarely do they grant more. You can learn more about the specifics of each payer's appeal process by reviewing your contracts. 

8-Minute Rule

How do I calculate the number of timed codes I should bill?

Most payers—including Medicare—use the 8-minute rule to determine the maximum number of units a provider can bill for a particular date of service. Each unit of a timed code represents 15 minutes spent providing that service. The following excerpt captures the 8-minute rule at its most basic level: “Medicare adds up the total minutes of skilled, one-on-one therapy and divides that total by 15. If eight or more minutes are left over, you can bill for one more unit; if seven or fewer minutes remain, you cannot bill an additional unit.” Of course, nothing about Medicare is basic.

When documenting the number of minutes I spent providing each service, can I round up?

As Brooke Andrus writes in this blog post, “Rounding might seem like a convenient—and mostly harmless—way to simplify your billing calculations. But to an auditor, a constant stream of perfect 15-minute treatment increments looks pretty fishy—and it could lead to billing for more skilled time than you actually logged with a patient.” Thus, it’s imperative that you record the time you spent providing each service to the exact minute.

What major payers use the 8-minute rule?

Most payers use a version of the 8-minute rule, but the nuances of the rule may vary from payer to payer. That's why we recommend checking with your payers to make sure you understand the rules.

Functional Limitation Reporting

If a patient is receiving treatment for two different issues from two therapists in different disciplines (e.g, PT and OT), do both therapists need to complete functional limitation reporting (FLR)?

In this case, both practitioners would complete FLR separately and independently of one another. When a patient is receiving treatment in two different disciplines—such as physical therapy and occupational therapy—Medicare tracks FLR for each discipline separately. Thus, the patient can simultaneously have one primary functional limitation for OT and another primary functional limitation for PT.

Cash-Pay Patients

How do I bill?

The simple answer to this question is that instead of billing a third-party payer and waiting for reimbursement, you’d bill the patient directly for the services provided. The patient could then collect reimbursement from his or her insurance company, depending on the policy’s stance on out-of-network providers. However, the long answer—which takes into consideration the nuances of Medicare and Medicaid patients—is a lot more complex. For everything you need to know about billing cash-pay patients, please read this three-part series by Jarod Carter, these posts by Ann Wendel, and this ultimate cash-based FAQ.

What do I charge?

To set your fee schedule for cash-pay therapy and wellness patients, Wendel says you’ll want to consider details specific to your practice, including overhead costs, caseload size, and clinic location as well as the amount of income you need to generate to live on and keep your practice running smoothly.

Don’t see your question? Ask it in the comments below.