Billing Scenario’s for PT & OT: Part 1
This week, I will provide 3 billing scenario’s that can be applicable to either outpatient physical therapy or outpatient occupational therapy services and provide the billing answer for Medicare beneficiaries and those insurance carriers that follow the Medicare Program billing rules (i.e. “8-minute rule) and will also provide the billing answer for those insurance carriers that do not follow the Medicare Program billing rules, rather, follow the definition of a substantial portion of a time-based CPT per the American Medical Association (AMA).
Two articles that you may want to read prior to continuing on with this article are “What CPT Codes Does the “8-Minute Rule” Apply To” and “What is Substantial of a Time-Based CPT Code“.
Lets begin!
Scenario #1
- 16 Minutes of joint mobilizations, soft tissue mobilization, and myofascial techniques
- 20 Minutes of range of motion and strengthening exercises
- 20 Minutes of unattended electrical stimulation for pain reduction
Scenario #1 Answer
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Scenario #2
- 10 Minutes of unattended electrical stimulation
- 12 Minutes of strengthening and active assist range of motion exercises
- 6 Minutes of manual therapy techniques to increase ROM
- 7 Minutes of functional activities of lifting and carrying
Scenario #2 Answer
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Scenario #3
- 27 Minutes performing a medically necessary reevaluation
- 12 Minutes patient on the upper body ergometer (UBE) for shoulder warm-up
- 18 Minutes of shoulder strengthening and range of motion exercises
- 12 Minutes of manual therapy techniques to increase AROM
Scenario #3 Answer
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I hope you found this article helpful. Watch for a Part 2 article where I will provide additional billing examples for physical and occupational therapy. Thank you for being a Gold Member!
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Rick what about if you only bill 7 mins of unattended electrical stim– is it still billable as it is an untimed code?
An untimed code would be 1 unit regardless of the amount of time provided.
Is scenario 2’s final answer incorrect? Wouldn’t it be 1 unit of E-stim UA and 1 unit of ther ex?
Thank you.
For which insurance?
For Non-Medicare; I copy and pasted from above:
“Scenario #2
10 Minutes of unattended electrical stimulation
12 Minutes of strengthening and active assist range of motion exercises
6 Minutes of manual therapy techniques to increase ROM
7 Minutes of functional activities of lifting and carrying”
“The final answer for insurance carriers where you are billing based on substantial portion of a 15-minute time-based CPT code is:
1 unit of 97530 (therapeutic activities)
1 unit of 97014 (unattended electrical stimulation)”
I think it is incorrectly written as 1 unit of 97530 (therapeutic activities), whereas it should be 1 unit of Ther ex 97110, correct? Ther ex has 12 min, and Ther act only had 7.
If I am incorrect, please help me understand. Thank you!
You are correct. Thank you for reading and catching. I did correct the answer.
How would we deal with billing for Medicare if we also concurrently treating a commercial insurance patient at the same time where a PT tech is involved?
If I am working 1:1 with a medicare patient doing manual interventions with them for 15 minutes, i am going to be able to bill for that medicare patient 1 unit of manual therapy. Can I also bill for the commercial insurance patient who is working with a tech under my orchestrated plan of care? Or can I only bill for the Medicare patient if the commercial patient is NOT being billed.
Thank you in advance!
Please read this article: https://gawendaseminars.com/can-i-double-book-medicare-patients-2/
When using the substantial portion method does total time play any factor? For example, would an example of therapeutic exercise x 23 minutes; therapeutic activity x 24 minutes and manual tx x 13 min be billable for 5 units? 97110-2 units, 97530-2 units and 97140 1 unit? (Even though that only totals 60 min session) thank you
Correct!
With a Medicare patient if you did:
10 minutes ultrasound
25 minutes therex
10 minutes manual therapy
Since the total time allows 3 units to be billed, and the time with therex also could be 2 units, are you able to bill:
0 units ultrasound
2 units therex
1 unit manual therapy
Thank you
That is one possibility.
Therapist performs passive range of motion to a joint. What billing code is most appropriate: Therapeutic Exercise (97110) or Manual Therapy techniques (97140)? What billing code is most appropriate if passive stretching was performed? Thank you for your time!
Pure PROM with no joint mobilization, STM, etc, would be 97110.
Hello,
Does the 8 minute rule apply to Medicare Part A beneficiaries (In-Patient)? If not, how are minutes and charges calculated in an in-patient setting.
Thank you
For true inpatients, the Medicare program pays the hospital via DRGs and not per CPT codes billed.
If we do 35 minutes of therapeutic activity and 20 minutes of therapeutic exercise, would that be 2 units of TA and 1 unit of TE, or 2 of each?
Medicare B Scenario: Ther Ex 15 min / Ther Act 18 min / Neuro Muscular Re-ed 6 min Total min = 39 min
It appears that anything over 15 min can be applied to another charge if appropriate. Therefore 3 min remaining of therapeutic activity and 6 min of Neuro Re-ed. The greater charge would be Neuro Re-ed.
Can you Bill: 97110 x 1 / 97530 x 1 / 97112 x 1
For Medicare, you are correct.