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In physical therapy, CPT (Current Procedural Terminology) codes describe the particular medical evaluation, treatments, and modalities patients receive during the sessions.
Unlike ICD (International Classification of Diseases) codes, CPT codes provide uniform information about all medical procedures and services to patients. The only difference you can find is - on the claim forms, where CPT codes examine services rendered rather than a patient's diagnosis.
This blog will help you learn about CPT codes. It will provide you with a list of CPT billing codes and evaluation codes and explain the importance of documentation for billing codes.
Current Procedural Terminology (CPT) codes refer to standardized language that healthcare providers and professionals use to list their patients' procedures and services. They are unique identification tags for the medical field, which might sound similar to barcodes.
The creation of the Current Procedural Terminology (CPT) Codes in 1966 by the American Medical Association (AMA) marked an important milestone in the standardization of reporting surgical, medical, and diagnostic procedures and services. The major purpose of CPT codes is to remove subjective interpretation and create uniform language to describe healthcare services and procedures.
CPT codes play a crucial role in billing and medical coding, which is a significant factor in coding systems. The CPT codes offer a standardized framework, allowing all healthcare payers and providers to interact effectively and ensure accurate reimbursement.
Here’s a list of CPT codes:
Includes: The CPT code 97110 includes strengthening, endurance, ROM, and flexibility exercises.
Direct Contact: Must involve one-on-one time with the patient.
Examples: Treadmill walking and bicep curls.
Ambulation for Endurance: Included but not gait training.
Billing: Billed in 15-minute increments; requires documentation of exercises and goals.
Reimbursement Rate: Typically lower than therapeutic activities (97530) because of the perceived skill level needed.
Documentation Requirements: Body part treated, specific exercises performed, purpose of exercises, and volume (sets, reps, resistance, time).
Comparison to Other Codes:
For an exhaustive list of reimbursement rates for CPT code 97110 across different insurance companies, Click Here.
Includes: The CPT code 97112 includes activities that facilitate re-education of movement, balance, posture, coordination, and proprioception/kinesthetic sense.
Examples: Stabilization exercises, Kinesiotaping, inhibition, or facilitation.
Additional Activities: Ergonomic training, Desensitization, plyometrics, and improving motor control.
Foam Rolling: Included to facilitate muscle contraction or desensitization of a painful region before exercise.
Focus on: High-level coordination and cueing to retrain neuromuscular output.
Documentation Requirements: Include specific exercises performed and their purpose related to functional goals.
Reimbursement Rate: CPT 97112 may yield higher reimbursement rates compared to other codes due to the complexity and skill required in the interventions performed.
For more information on reimbursement rates for CPT code 97112 across different insurance companies: Click Here
Includes: The CPT code 97116 includes sequencing, assistive devices, training with modified weight-bearing status, and completing turns with proper form.
Focus on: Emphasizing biomechanics of the gait cycle; simply walking for cardiovascular health does not qualify as gait training.
Documentation Requirements:
Clinical Skill Required:
Billing Guidelines:
Compliance Considerations: To avoid compliance risks, ensure accurate minutes are recorded and clear relationships between gait training and treatment goals are documented.
Reimbursement rates for the CPT Code 97116 can vary across different insurance companies.
Includes: The CPT code 97140 includes joint mobilization, muscle energy techniques (using resistance applied by the therapist), soft tissue mobilization, manipulation, manual traction, and manual lymphatic drainage in the list of PT billing codes.
Manual Resistive Exercise: This can be included in this category or therapeutic exercise involves resistance applied by the therapist to improve strength or endurance.
Muscle Energy Techniques: Considered part of neuromuscular re-education.
Reimbursement Rate: Typically lower than therapeutic exercise, neuromuscular re-education, and therapeutic activities.
Clinical Focus on: Emphasizes exercise prescription and load management rather than massage therapy.
Effectiveness: Manual therapy techniques can complement a well-structured exercise program but should not create dependency.
Documentation Requirements: The specific techniques used, patient response, and justification for the therapy must be included as part of the treatment plan.
For an exhaustive list of reimbursement rates for CPT code 97112 across different insurance companies: Click Here
Includes: The CPT code 97150 offers therapeutic procedures to two or more patients simultaneously on land or in an aquatic setting.
Examples:
Attendance Requirement: The PT or PTA must be constantly present; it does not require one-on-one time with each patient.
Focus Areas: Enhancing social interaction, motivation, and peer support among participants, contributing to improved therapeutic outcomes.
Medicare Requirements: The type of group and number of participants must be documented.
Attendance Requirement: The PT or PTA must be constantly present; it does not require one-on-one time with each patient.
Reimbursement Rate: Generally lower than one-on-one therapy sessions.
Documentation Needs: Include details about the group dynamics and individual participation for billing and compliance purposes.
Reimbursement for CPT 97150 can vary significantly depending on the payer and the region.
Includes: The CPT code 97530 includes dynamic activities designed to improve functional performance, requiring direct one-on-one patient contact.
Examples: Bed mobility, sit-to-stand training, step-ups/stair negotiation, hip-hinge training, squatting mechanics, throwing a ball, step-ups/stair negotiation, swinging a bat or golf club, car transfer training.
Focus Areas: Enhancing mobility, strength, balance, and coordination through real-life movements and activities of daily living (ADLs).
Reimbursement Rate: Higher than therapeutic exercise (CPT 97110) due to the need for higher skill levels and repetition to achieve mastery.
Documentation Requirements:
Billing Guidelines: Billed in 15-minute increments; must meet the eight-minute rule for billing one unit.
Clinical Application: Used to address multiple parameters simultaneously, aligning with specific treatment goals and improving overall functional performance.
For an exhaustive list of reimbursement rates for CPT code 97112 across different insurance companies: Click Here
Includes: Training in activities of daily living (ADLs), compensatory training, safety procedures, meal preparation, and assistive technology or adaptive equipment.
Examples:
Reimbursement Rate: Typically higher than therapeutic activities, therapeutic exercise, and neuromuscular re-education due to the necessity for skilled intervention.
Clinical Focus: Aims to enhance independence in self-care and home management through direct one-on-one contact with the provider.
Billing Guidelines: Billed in 15-minute increments; must meet the eight-minute rule for one unit.
Documentation Requirements: Must include justification for the therapy, patient capacity to learn, specific techniques used, and correlation to functional goals.
Transfer/Transition Training: This can be included if the patient struggles with getting up from a chair; it is not applicable if the patient is using sit-to-stand for strengthening.
A low-complexity evaluation (97161) refers to a stable clinical presentation, usually without some notable factors. The evaluation focuses majorly on performing fundamental tests, reviewing the patient's history, and creating the best treatment plan.
A CPT code 97162 is known as a moderate-complexity physical therapy evaluation. This evaluation includes a complete assessment of the patient's condition, including current health status, medical history, and other factors that may impact their treatment plan.
It also involves using standardized measures and tests to evaluate distinct aspects of the patient's physical functioning.
A high-complexity evaluation (97163) is generally used for patients with three or more personal factors or an unstable clinical presentation.
These evaluations include a detailed view of several body systems and the use of various measures and tests to accurately assess the patient's condition.
Pt re-evaluation codes play a significant role in checking the progress and adjusting the pt treatment plans of patients. The 97164 CPT code (introduced in 2017, replacing the 97002 code) was used to bill and document these re-evaluations accurately.
These re-evaluations are conducted when there is a crucial change in the treatment plans, response to therapy, or patient condition. They allow therapists to modify the treatment plans, monitor the patient’s progress, and ensure the effectiveness of therapy.
Here’s a list of some other physical therapy CPT codes:
The CPT code 97010 is an application of a modality to one or more areas, specifically hot or cold packs.
The reimbursement rates for CPT 97010 can vary across different insurance companies, with some providing minimal payment and others including it as part of a collective service under another main service code.
The CPT code 97012 can be reported for mechanical traction. Traction is generally used for joints, especially of the cervical or lumbar spine, with the expectation of relieving pain or increasing the joint’s range of motion.
Reimbursement for CPT Code 97012 can vary on different factors, including the geographic location of the practice, the insurance provider, and the particular circumstances of the treatment.
The 97014 CPT code is used for billing services when electrical stimulation is provided to one or more areas of a patient’s body.
Reimbursement for CPT code 97014 varies among different payers. For example, Optum does not provide reimbursement for this code, while Blue Cross and Blue Shield of Louisiana apply a multiple procedure reduction policy when certain codes are billed on the same day.
CPT code 97016 can be reported when a vasopneumatic device is applied during the treatment of one or more areas of a patient's body.
CPT code 97032 describes the application of electrical stimulation therapy to one or more body parts to treat muscle-related disorders and acute pain.
Reimbursement rates for CPT code 97032 can vary significantly depending on the insurance provider and the geographical location of the practice.
CPT 97035 describes physical therapists' use of ultrasound as a modality to treat muscle-related problems in patients.
The reimbursement rates for CPT Code 97035 can vary significantly depending on the insurance company and the region.
While CPT codes and ICD-10 are the primary focus of the PT billing codes, modifiers are also important. They offer extra details to patients that help them meet insurance rules and ensure accurate payments. Modifiers clarify the codes and ensure everything is processed correctly.
Modifier 59 is one of the most commonly used HCPCS modifiers but is often misused. This can lead to reviews, audits, and even legal issues such as fraud cases. To prevent this, four new 'X' subset modifiers were introduced to help reduce errors and make the claim process work faster and more accurately for providers.
Under some circumstances, the physician might need to specify that a service or procedure was independent or different from other services performed.
Modifier 59 is used to examine procedures and/or services that are usually reported together but are appropriate under some circumstances. This may show a distinct site or organ system, distinct surgery or procedure, distinct patient or session encounter, separate lesion, injury (or injury area in extensive injuries), or incision/excision not generally performed on the same day by the same physician.
Medicare noticed that providers were overusing the modifier 59, often just adding it to unbundle codes and getting both paid, even when it wasn’t appropriate. To fix this issue, Medicare now requires providers to clearly explain why they’re using the 59 modifier, making sure it’s justified and documented for each case.
To help with this, Medicare introduced four new modifiers for Part B claims:
Here is a video by the American Institute of Healthcare Compliance on “how to use modifier 59, XE, XP, XS, and XU and how NCCI prevents payment for codes that report overlapping services.”
In healthcare, keeping accurate and precise records is crucial, especially for proper medical billing. Good documentation is key to ensuring the system runs smoothly and stays financially stable.
When medical professionals carefully record patient information, diagnoses, treatments, and procedures, it helps reduce claim denials and delays. Accurate records give insurance companies all the details they need to process claims quickly, which means healthcare providers get paid faster. Accurate documentation and professional medical billing create a smooth financial process, benefiting healthcare providers and patients.
1. Medical Coding Accuracy: Accurate medical coding is essential for correctly translating diagnoses, procedures, and services into billing codes. This process relies heavily on detailed documentation. Proper coding ensures that healthcare providers are fairly reimbursed and helps prevent audits or disputes. Documentation is the link that provides the information needed to assign the right codes.
Matching diagnostic codes (ICD-10) with procedure codes (CPT) is key to ensuring the billed services accurately reflect the patient's condition and treatments. This leads to correct payments and helps maintain clear medical records. Accurate documentation reduces the risk of coding errors, supporting a smooth billing process.
2. Improves Auditing Efficiency: Keeping detailed records of patient visits, diagnoses, treatments, and procedures helps make audits more accessible and efficient. When medical professionals document everything clearly, auditors can easily check and confirm the services provided. This reduces mistakes, discrepancies, and potential fraud. Good records also mean that responses to audit questions can be quick, which helps avoid penalties and supports the financial health of healthcare institutions.
3. Clarity in patient care: Good documentation is crucial for clear communication between healthcare providers. Doctors and nurses ensure that services are clearly understood by recording detailed and accurate patient information. This clarity also helps with accurate billing. Plus, when patients see that their health information is carefully and securely documented, it builds their trust in the healthcare facility. This trust strengthens patient relationships and encourages loyalty.
4. Revenue cycle optimization: Good documentation makes the revenue cycle run smoothly. By clearly recording patient details, services, and diagnoses, healthcare providers ensure that billing is fast and accurate. This helps avoid delays and ensures timely payments. Detailed documentation also prevents revenue leakage—services might be missed or billed incorrectly. With accurate records, healthcare organizations can spot and fix any billing issues, ensuring every service is billed correctly and nothing is overlooked.
5. Reduces delays and claim rejections: When healthcare providers carefully record patient information, treatments, and procedures, billing codes are matched accurately and reflect the services provided. This reduces the chances of claim denials and improves the likelihood of getting claims approved by insurance companies. Claims might be rejected or delayed if documentation is incomplete or missing details. To avoid these issues, it’s essential to include all necessary information. Accurate records help prevent extra inquiries from insurers and ensure a smooth process for getting claims paid.
6. Allows you to Credential with More Payers: Credentialing with more payers and offering diverse payment options can significantly improve patient acquisition, retention and engagement.
Additionally, ensuring fully compliant documentation and billing practices and using an EMR to automate billing can ensure minimal staff training and gives you the freedom to work with multiple payers.
The Centers for Medicare & Medicaid Services (CMS) introduced the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits to streamline coding practices and prevent overpayment for Part B claims. These edits are designed to help healthcare providers submit accurate, comprehensive codes instead of breaking them down into smaller, potentially inappropriate parts. By checking for mutually exclusive code pairs, NCCI ensures that only valid code combinations are billed together, helping avoid payment errors.
In addition to PTP edits, NCCI also includes unit-of-service edits that limit how many times a service can be billed for each HCPCS code, ensuring accuracy in billing and reimbursement.
Gawenda Seminars & Consulting has created a helpful “cheat sheet” for using Modifier 59 in outpatient therapy. This guide includes the most common CPT codes for Physical Therapists (PTs), Occupational Therapists (OTs), and Speech-Language Pathologists (SLPs), showing which codes can and can't be billed together on the same day by the same provider.
Sticking to best practices for documentation is key to getting the most out of medical billing. This means keeping thorough records of patient details, like their background and medical history, which helps ensure billing is spot-on. Updating codes regularly to match industry standards is essential for avoiding claim denials and ensuring payments are processed correctly. Following these practices helps make billing more accurate and efficient.
Mastering and learning the list of CPT codes for physical therapy is a collaborative task. Therapists are required to have a thorough knowledge of the codes for precise and accurate documentation and compliance. Here, partnering with all-in-one management software for PT clinics like Spry can transform the process into a seamless, managed, and organized system.
Spry empowers you to optimize practice performance, code confidently, and ultimately focus on what truly matters—providing exceptional patient care and safeguarding your practice’s financial well-being. It also offers a comprehensive solution for patient engagement, covering scheduling, billing, and documentation and streamlining your workflow.
Spry also has expertise in simplifying record-keeping by streamlining the documentation processes to minimize the risk of errors and compliance issues. We offer customized billing solutions that transform your financial well-being. Experience high revenue growth via a swift reimbursement process that frees you from manual errors and paperwork.
We are highly committed to offering transparency and guaranteeing a seamless billing experience by providing excellent care to all the patients along with some interesting features like EMR & smart charting, integrated billing, insurance eligibility, SPRY-RTM assessment tool (to provide solutions to all your traditional therapy models), and more.
So are you ready to master physical therapy CPT codes that Spry offers to streamline your business operations and practice management skills to a new level?
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