Billing Scenario’s for PT & OT: Part 1

October 7, 2019
 / 
Rick Gawenda
 / 

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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This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

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  1. Rick what about if you only bill 7 mins of unattended electrical stim– is it still billable as it is an untimed code?

  2. 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.

      1. 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!

  3. 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!

      1. 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

  4. 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

  5. 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!

  6. 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

    1. For true inpatients, the Medicare program pays the hospital via DRGs and not per CPT codes billed.