Physical Therapy (PT)

Physical Therapy Billing & Credentialing

Billing and coding for physical therapy (PT) practices are evolving every year. Even with the new 3-level evaluation codes put into place this year, CMS is still collecting data throughout 2017 to see if there need to be more changes made to how physical therapists are reimbursed. There are multiple rules and regulations for physical therapy billing.

Every health insurance company is different, which is why checking eligibility, submitting authorizations and documentation and adhering the correct modifiers to your patient’s claims can be a daily task that many offices struggle to learn and understand. Medwave and its professionally trained staff are here to help you and your office succeed in submitting your claims correctly.

Keeping Compliant

The first step to ensuring that you and your medical practice are on the right track is to make sure that you are documenting your patient’s visits correctly. Correctly documenting your patient’s notes can be the difference between getting paid and acquiring authorizations and losing thousands of dollars in income a year.

New Physical Therapy Evaluation Codes

As of January 1st, 2017, the CPT code 97001 for a physical therapy evaluation and 97002 for physical therapy re-evaluation will be replaced by 4 new CPT codes. The new codes will allow therapists to make a more specific evaluation based on the complexity of the patient’s diagnosis and performance.

Patient Specific Functional Scale

The patient-specific functional scale score is being used by multiple insurance companies as a way to properly measure orthopedic conditions. Before being evaluated, the patient is asked to list as many as three activities they are having trouble performing based on their diagnosis. Once identified, they will point to a number scale from 0-10, 10 being fully functional, and score how they deem themselves able to perform that activity. This will be completed before the initial evaluation and upon every re-evaluation after.

Patient-specific activity scoring scheme (Point to one number):

0          1          2          3          4         5         6          7          8          9          10

Unable to perform                                                                                          Able to perform

See: Highmark Patient Specific Functional Scale

Functional Reporting using G-codes

As of January 1st, 2013, it is required to append “G” codes to the initial visit, at least every 10th and upon the discharge of treating a patient under Part B Medicare. Highmark BCBS has now initiated the same policies for tracking the functional limitations of a patient. As of July 2017, all claims will be denied if G-codes and their modifiers are not used.

Severity Modifiers

Modifiers are needed to more accurately show the level of functional status the patient currently has and the goal being reached. There are a total of seven modifiers to choose from:

When submitting claims for Medicare it is still necessary to append the GP modifier to show the service is being performed as outpatient physical therapy.