Physical Therapists’ Guide to CPT Codes

Like ICD codes, CPT codes communicate uniform information about medical services and procedures to healthcare payers. The difference is that on claim forms, CPT codes identify services rendered rather than patient diagnoses.

What is a CPT code?

As mentioned in the intro above, while CPT codes are similar to ICD-10 codes in that they both communicate uniform information about medical services and procedures, CPT codes identify services rendered rather than diagnoses. In short, CPT codes are procedure codes, and ICD-10 codes are patient diagnosis codes.

Here is an example of ICD-10 and CPT codes in use: Today, if you diagnose a patient with a right Total Knee Replacement and post-surgical knee pain, you would use the ICD-10 codes Z47.1 and M25.561 to denote aftercare for a joint replacement surgery and knee pain. Then, you might incorporate therapeutic exercises—CPT code 97110—into your plan of care to retrain quadriceps strength (among other things). Your claim would need the ICD-10 diagnosis codes and any corresponding treatment codes—CPT codes—that follow. 

What are the Most Common Physical Therapy CPT Codes?

Below are the 20 top CPT codes recorded within WebPT between September 2022 and February 2023:

CPT codes are copyright 2022 American Medical Association. All rights reserved.

A Note on CPT Code 97110

Perhaps the most common physical therapy CPT code seen is 97110—therapeutic exercises. This often denotes the bread and butter of what PTs do, especially with patients suffering from musculoskeletal dysfunctions. But you may be surprised to find it can be one of the worst CPT codes to use for payment purposes. 

That is why understanding the why behind each code is so important so that you can correctly document and use the right CPT codes that denote the correct treatment for the patient and help you get paid the most for what you—the expert—deserve. If you would like more information on how to correctly apply different CPT codes check out this blog post that describes some of the differences between 97110 and 97530—therapeutic activities. Or if you would like to see how AI can help make the whole process even easier—and less time-consuming—check out WebPT’s partnership with PredictionHealth.

What is Modifier 59? How Do I Use It?

The CPT Manual defines modifier 59 as the following:

“Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures [and/or] services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

That explanation is a bit dense, and it’s not super relatable. But that’s because modifier 59 is intended mainly for surgical procedures, so the definition leans a great deal that way.

So, how does modifier 59 come into play in the therapy setting? If you’re providing two wholly separate and distinct services during the same treatment period, it might be time for modifier 59. 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. It’s therefore your responsibility as the therapist to determine whether you’re providing linked services or wholly separate services. This, in turn, determines whether modifier 59 is appropriate.

Modifier 59 Example

For example, let’s look at one of the most commonly billed codes: 97140 (manual therapy techniques like mobilization/manipulation, manual lymphatic drainage, or manual traction on one or more regions, each for 15 minutes). According to NCCI, the following are considered linked services when billed in combination with 97140: 95851, 95852, 97018, 97124, 97750, and 99186. So, if you bill any of these codes with 97140, you’ll receive payment for only 97140. Medicare uses this example on its site to explain the appropriate use of modifier 59 among rehab therapists.

CMS states that when billing 97140 and 97530 (therapeutic activities; direct, one-on-one patient contact by the provider; or use of dynamic activities to improve functional performance, each for 15 minutes) for the same session or date, modifier 59 is only appropriate if the therapist performs the two procedures in distinctly different 15-minute intervals. This means that you cannot report the two codes together if you performed them during the same 15-minute time interval.

If the care you provide meets the appropriate criteria, you can add modifier 59 to 97530 to indicate it was a separate service and should be payable in addition to the 97140. The same holds true for billing 97140 with 95851, 95852, 97018, or 97750. However, you can never bill 97124 with 97140—and you cannot add any modifier to change this restriction, because these codes are mutually exclusive procedures, according to CMS.

When Should I Use Modifier 59?

Modifier 59 can monumentally impact your Medicare reimbursements, and unfortunately, it’s the modifier physical therapists struggle with most. Perhaps that’s because the CPT Manual doesn’t offer the most helpful guidance. Therefore, we recommend asking the following questions to decide if and when you should use modifier 59.

Are you billing for two services that form an NCCI edit pair?

There are instances in which it’s appropriate to use modifier 59 in conjunction with physical therapy services. Recognizing those instances, though, requires you to recognize NCCI edit pairs. To make a long story short, edit pairs—also called linked services—are sets of procedures that therapists commonly perform together. If you submit a claim containing both of the codes in an edit pair, you’ll only receive payment for one of the procedures, because the payer will assume that one of the services was essentially “built into” the other.

Did you perform those two services separately and independently of one another?

Okay, so you’re dealing with an edit pair. But what if—for whatever reason—you actually didn’t perform those services together? That’s where modifier 59 comes into the picture. 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 payments for each procedure. 

Does your documentation support your assertion that you performed the two services separately and independently of one another?

When it comes to telling your patients’ stories, codes and modifiers can only say so much. It’s on you to fill in the plot holes with detailed, defensible documentation. After all, your documentation justifies your billing decisions—and if you’re ever faced with an audit, your notes will be your main source of proof that those decisions were the right ones. That means you should never:

• append modifier 59 simply because you know it will guarantee payment.
• skimp on your documentation—or intentionally document vaguely or misleadingly.  
• routinely use the 59 modifier in conjunction with re-evaluation codes. (Doing so could throw up a red flag to your payers.) 

Let’s assume that, yes, your documentation does support your assertion that you performed the two services separately and independently of one another. So, next, you’d ask:

Is a more descriptive modifier available?

Clinicians, coders, and billers should only use modifier 59 as a last resort (i.e. when there’s no better option). As the CPT Manual states, “...when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”

Now, you’ve probably heard talk about the new set of modifiers that CMS created for providers to use in place of modifier 59, when appropriate. The new modifiers—XE, XP, XS, and XU—are intended to bypass a CCI edit by denoting a distinct encounter, anatomical structure, practitioner, or unusual service. However, even though these modifiers went into effect on January 1, 2015, The APTA has provided this algorithm to assist in properly using these modifiers, and we have this quick read on when to use the X modifiers. But as there continues to be some confusion around the specifics of the X modifiers, we recommend contacting your payers first before applying any of them to your claims.

What are the Most Commonly Used CCI Edits for PT, OT, and SLP Private Practice Settings?

Below is a table with all of the common CCI edit pairs related to different therapy types, courtesy of PT compliance expert Rick Gawenda, owner of Gawenda Seminars & Consulting. Here’s how to use the chart:

Note that this is the CCI edit list from Medicare. Most government payers—like Medicare, Tricare, and Medicaid—use this same list. However, private payers often create their own edit pairs; therefore, there is no guarantee they will pay, even with an applied modifier 59.

Version 27.0 Correct Coding Initiative (CCI) Edits

Current as of January 2021

How Do I Bill for an Initial Evaluation or Re-evaluation?

As of January 1, 2017, PTs and OTs should no longer use the CPT codes 97001, 97002, 97003, and 97004 to bill for initial evaluations and re-evaluations. That’s because these codes have been replaced by a new set of eight evaluative codes: two for re-evaluations and six for evaluations.

But, this isn’t a simple swap-out. The new codes for initial evaluations are tiered according to the complexity of the evaluation performed. So, PTs and OTs now must determine whether a patient evaluation is low complexity, moderate complexity, or high complexity—and then select the CPT code that correctly represents that level of complexity. Here’s a brief breakdown of the new codes:

Replacement CPT Codes for 97001

Replacement CPT Codes for 97003

Replacement CPT Codes for 97002 and 97004

Looking for more in-depth guidance on how to select the correct level of complexity for each PT or OT evaluation? Check out this blog post and download.

When should I bill for an evaluation vs. a re-evaluation?

On the surface, the difference between billing an initial eval and a re-evaluation may seem straightforward, but that’s not always the case. Keep reading for three example scenarios to help you make what can occasionally be a challenging decision (adapted from this post by WebPT’s Kylie McKee). For several more examples, check out the post in full.

Scenario 1

According to McKee, if a current patient develops a newly diagnosed—yet related—condition, then you’ll want to perform and bill for a re-eval using code 97164. For example, if a high-school soccer player is receiving care for left patellofemoral pain syndrome and develops similar symptoms in their right knee, then you would perform (and bill) for a re-eval and update the existing plan of care. After all, as McKee explains, “a re-evaluation is triggered by a significant clinical change in the condition for which the original plan of care was established.” The patient should now be receiving care for bilateral patellofemoral pain syndrome.

Scenario 2

If a current patient develops a newly diagnosed—yet unrelated—condition, then you’ll want to perform and bill an initial evaluation. For example, if the same soccer-playing patient who has been receiving care for bilateral patellofemoral pain syndrome shows up with lower back pain related to scoliosis, then you would want to perform and bill for an initial evaluation using codes 97161–97163. After all, “The second, unrelated problem (i.e., with a different body part or body system) may not result in a change to the original condition.”

Scenario 3

If a former patient returns to therapy after discharge and requests care for the same issue you were treating previously, you would most likely perform an initial evaluation using codes 97161–97163. McKee cautions that there isn’t a whole lot of formal guidance on how to handle this scenario, but if it’s been 60 days since the patient received care from you, Medicare requires you to begin a new case. And because you’ve already discharged the patient, it makes sense that you would start over if that patient reinjures their left rotator cuff and needs your services again. For commercial payers, though, you should defer to the payer’s rules and your state practice act.

Should I bill for a re-evaluation each time I complete a progress note?

A typical progress note, even one with functional limitation reporting, does not require a re-evaluation CPT code (97164 or 97168). In fact, you should only ever bill for a re-evaluation if one of the following situations apply:

• There are new clinical findings.
• The patient fails to respond to the treatment outlined in the current plan of care.
• The professional assessment indicates a significant improvement, decline, or change in the patient’s condition or functional status that was not anticipated in the plan of care for that interval.

Where Can I Find the Physician Fee Schedule Final Rule?

The CY 2024 Physician Fee Schedule Final Rule is available here.

Let WebPT help handle the burden of Medicare modifiers.

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