Payment Changes in CPT Codes Billed by Therapists

January 15, 2018
Rick Gawenda

For those of you that provide outpatient therapy services to Medicare beneficiaries, many of you will see a decrease in your payments in 2018 compared to 2017 due to a reduction in payment of the most commonly billed CPT codes to the Medicare program. However, several CPT codes that perhaps you should have been billing all these years will see an increase in their payment rate in 2018 compared to 2017.

This change in payment is due to changes in the work relative value unit (RVU) and practice expense (PE) RVU of the CPT codes. The work RVU takes into account the relative level of time, skill, training, and intensity to provide the service. The PE RVU takes into account the cost of running a practice such as mortgage or rent payment, office supplies, equipment and non-physician staff costs.

I won’t bore you with the details on the work and PE relative value units (RVUs) of the most commonly billed CPT codes under a physical therapy and/or occupational therapy plan of care for 2018 compared to 2017. What I will provide you with are the payment changes in the most commonly billed CPT codes under a physical therapy and/or occupational therapy plan of care for 2018 compared to 2017. Codes discussed in this article will include, but are not limited to, mechanical traction, iontophoresis, therapeutic exercise, neuromuscular reeducation, aquatic therapy, massage, manual therapy, therapeutic activities, wheelchair management, orthotic management and training and prosthetic management and training.

Payment for each CPT code will vary dependent on your payment locality due to the geographic price cost index (GPCI). The GPCI is used by the Medicare program to adjust payment rates to take into account regional and practice-specific factors.

In calendar year 2018, there are approximately 112 different payment localities. For the purpose of this article, I will use Los Angeles county to show the pay differences in 2018 compared to 2017 on the most commonly billed CPT code under a Medicare Part B physical and/or occupational therapy plan of care.

CPT Code       2018 Payment Rate       2017 Payment Rate       Change

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  1. Thank you for giving us the breakdown! Do you think that commercial payers will follow suit?

    1. Thank you for the feedback. As with any changes the Medicare program makes, my opinion is some insurance carriers will follow suit and others will not.

  2. As always thanks for the detailed up to date information! How could I find out these changes in MA and RI?

    1. At the end of the article is the link to access the fee schedule on the CMS website as well as the APTA website.

  3. The CPT definition of TA 97530 does not explicitly include (or exclude) stair activities, but the definition of Gait 97116 specifically DOES include stair activities. Do you have recommendation on language and categorization with stair “stuff”? (literal stair climbing, step up/down reps, plyo drills etc)- obviously can fall into a few different areas depending on therapeutic intent.

    My thoughts – “functional training” – TA; “mechanics/sequencing/patterning” – Gait; “power/agility/plyo” – NMR? TE? “functional endurance” – hard to categorize since function suggest TA / endurance suggests TE?

    I imagine this will be a common question as people re-evaluate their coding habits, so thought it would be relevant to post.

    Thanks for being a consistent source of clarity!

    1. If doing stair training, that would be considered gait training and billed under CPT code 97116. 97530 would be dynamic functional activities and could include some of the interventions you mention, but not stair training.

  4. Can you provide any insight on why 97124 is now nearly $4 more per unit than 97140? MT is an encompassing code for so many procedures and one spends notable CE on developing skills related to this code. Historically, I believed it was discouraged to use 97124 as a easily deniable code code and we needed to use a more skilled code as 97140. Now, do we use it more and risk changes to our data footprint? Do we separate STM as massage (97124) and everything else (JM, MRF) as 97140? Do we add 97124 to our core 4 codes and make it core 5? How do we advise our PTs/PTAs?

    1. CPT code 97124 pays more in 2018 due to an increase in the work and practice expense relative value units. You would want to look at the CPT code description for 97124 and get an understanding of petrissage and effleurage, compression, etc.

  5. We are finding out that more and more payers in our area are not reimbursing for 97033, iontophoresis. We do not want to upset the referring physicians, so we continue to provide the service. How are providers handling this? Are they now billing the patients directly for the service if denied by the insurance? Thank you.

    1. In my opinion, this has nothing to do with upsetting the physician. First, you need to look at the research and has iontophoresis been shown to work in the condition(s) you are using it on? If yes, then the insurance carrier has the right to determine if they will pay for iontophoresis or not. If not, for Medicare, I would recommend using an ABN. For all non-Medicare patients, you need to look at your contracts and do your contracts allow you to bill the patients for services not covered by the insurance carrier.