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.
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.
What should you be including in your documentation?
- Most current ICD-10 codes
- Updated CPT Evaluation codes
- Patient Specific Functional Scale (PSFS)
- G Codes upon Evaluation and Re-evaluation and at least every 10th visit
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.
New CPT Codes for Physical Therapy
- 97161 – Physical Therapy Evaluation – Low Complexity
- 97162 – Physical Therapy Evaluation – Moderate Complexity
- 97163 – Physical Therapy Evaluation – High Complexity
- 97164 – Physical Therapy Re-evaluation
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
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.
How do I know which G-code to use?
Based on the patients DX codes, you would choose the corresponding G-codes that best explain the patient’s functional limitations. You will always need to include 2 of the 3 codes in a set. You will either use the current status code with the goal status code or the current status code and discharge code. These codes will also need to be included in the patient’s documentation for every date of service:
Mobility G-code set:
- G8978 Current Mobility status
- G8979 Mobility goal status
- G8980 Mobility D/C status
Changing & Maintaining Body Position G-code set:
- G8981 Body position current status
- G8982 Body pos goal status
- G8983 Body pos D/C status
Carrying, Moving & Handling Objects G-code set:
- G8984 Carry current status
- G8985 Carry goal status
- G8986 Carry D/C status
Self Care G-code Set:
- G8987 Self care current status
- G8988 Self care goal status
- G8989 Self care D/C status
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:
Modifier Impairment Limitation Restriction
- CH – 0 percent impaired, limited or restricted
- CI – At least 1 percent but less than 20 percent impaired, limited or restricted
- CJ – At least 20 percent but less than 40 percent impaired, limited or restricted
- CK – At least 40 percent but less than 60 percent impaired, limited or restricted
- CL – At least 60 percent but less than 80 percent impaired, limited or restricted
- CM – At least 80 percent but less than 100 percent impaired, limited or restricted
- CN – 100 percent impaired, limited or restricted
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.
Our staff is here to help you and your office succeed in preparing claims and getting reimbursed. Contact us today to see how we can be the best asset to your physical therapy practice (in the Greater Pittsburgh region and rest of the United States), by helping you get paid fast and efficiently.