Physical Therapy Billing Units

What are Physical Therapy Billing Units?

Physical Therapy Billing Units refer to the measure used in the billing process for services provided by physical therapists. These billable units are essential for accurate billing and reimbursement of physical therapy services. Billing units can be determined based on various factors, such as the type of service provided, the therapy session's duration, and the treatment's complexity.

Physical therapy billing units are typically used with Current Procedural Terminology (CPT) codes, standardized codes assigned to specific medical procedures and services. These codes help accurately describe the services provided during a therapy session and ensure that the billing unit accurately reflects the care delivered.

Proper documentation of the services provided is crucial for accurate billing. Physical therapists must accurately document the services rendered, including the type of therapy, duration, and other relevant details. This documentation ensures that the billing accurately reflects the care delivered and helps verify insurance coverage for the patient.

Billing units for physical therapists play a crucial role in the financial aspect of a physical therapy practice. By accurately calculating billing units and using appropriate CPT codes, physical therapists can ensure fair compensation for their services and maintain successful healthcare provider practices. Utilizing practice management software can streamline billing and help healthcare providers manage their billing practices effectively.

Types of PT Billing Units

There are primarily two billing units in physical therapy billing codes: timed and untimed. Let's delve into each type, along with examples of standard codes for clarity:

Timed units

Timed units are based on the duration of the therapy session and are calculated using the "8-minute rule" established by Medicare. This rule states that one unit is billed if a particular service lasts between 8 and 22 minutes. If the service extends beyond 23 minutes, an additional unit is billed.

Examples of standard codes for timed units include:

• 97110: Therapeutic procedure, one or more areas, every 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, and flexibility.
• 97112: Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting and standing activities every 15 minutes.
• 97116: Gait training (includes stair climbing) with one or more of the following: parallel bars, walker, crutches, or canes, every 15 minutes.
• 97140: Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, every 15 minutes.

Untimed units

Untimed units are not based on the duration of the service but rather the service based on the specific service provided during the therapy session. These services are billed as a single unit regardless of the time spent.

Here are some of the common codes for untimed units:

• 97161: Physical therapy evaluation, low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics.
• 97110: Therapeutic procedure, one or more areas, every 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, and flexibility.
• 97112: Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting and/or standing activities every 15 minutes.
• 97140: Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, every 15 minutes.

It's essential for physical therapists to accurately select the appropriate codes based on the services provided during the therapy session to ensure proper reimbursement and compliance with billing regulations.

Types of codes used in PT Billing Units

In physical therapy billing, several codes are used to describe the services provided during therapy sessions accurately. These codes help ensure proper reimbursement and compliance with billing regulations. Here are the main types of codes used in PT billing units:

Current procedural terminology (CPT) 

CPT codes are standardized codes developed and maintained by the American Medical Association (AMA). They describe medical, surgical, and diagnostic services rendered by healthcare providers. In physical therapy, CPT codes report specific procedures and services provided during therapy sessions.

Examples of a CPT code or codes commonly used in physical therapy billing include:

• 97110: Therapeutic exercises
• 97112: Neuromuscular reeducation
• 97140: Manual therapy techniques
• 97750: Physical performance test or measurement

Healthcare common procedure coding system (HCPCS) level II 

HCPCS Level II codes are used primarily for billing products, supplies, and non-physician services not covered by CPT codes. In physical therapy, HCPCS Level II codes may be used for items such as durable medical equipment (DME) or supplies provided during therapy sessions. 

Here are some HCPCS Level II codes relevant to physical therapy:

• G0283: Electrical stimulation (unattended)
• L3908: Knee orthosis, with adjustable flexion and extension joint
• A4556: Electrodes, per pair

International classification of diseases, tenth revision, clinical modification (ICD-10-CM)

ICD-10-CM codes are used to report diagnoses and reasons for patient encounters. These codes describe the patient's condition or symptoms being treated during therapy sessions. While physical therapists typically do not diagnose conditions, they may use ICD-10-CM codes provided by referring physicians to support medical necessity for therapy services. 

Examples of ICD-10-CM codes related to physical therapy include:

• M54.5: Low back pain
• M17.9: Osteoarthritis of the knee, unspecified
• S83.5XXA: Sprain of unspecified cruciate ligament of the right knee, initial encounter

Modifier

Modifier codes are two-digit codes appended to CPT or HCPCS Level II codes to provide additional information about the service or procedure performed. These codes may indicate circumstances such as multiple procedures performed, bilateral procedures, or services provided by assistant personnel. 

Some modifier codes used in physical therapy billing include:

• 59: Distinct procedural service
• GP: Services delivered under an outpatient physical therapy plan of care

Advantages of using Physical Therapy Billing Units

Physical therapy billing units offer several advantages for physical therapists and healthcare providers. 

• Accurate billing: Billing units provide a standardized way to quantify the services provided during physical therapy sessions. By accurately documenting and calculating billing units, healthcare providers can ensure that their billing accurately reflects patient care.
• Transparent reimbursement: Billing units help healthcare providers and insurance companies understand the scope and complexity of the services rendered during therapy sessions. This transparency can facilitate reimbursement and reduce the likelihood of disputes or claim denials.
• Fair compensation: By using billing units, healthcare providers can ensure they receive fair compensation for their services. Billing units consider factors such as the duration and complexity of therapy sessions, allowing providers to be reimbursed appropriately for their time and expertise.
• Compliance with regulations: Properly documenting and calculating billing units helps ensure compliance with billing regulations and guidelines set forth by government agencies and insurance companies. This reduces the risk of audits, penalties, or legal issues related to improper billing practices.
• Streamlined workflow: Billing units can streamline the billing process by providing a standardized framework for documenting and reporting services. This can help improve efficiency and reduce administrative burden for healthcare providers and billing staff.
• Improved patient care: Accurate billing practices contribute to overall practice management and financial stability, ultimately supporting high-quality patient care. When healthcare providers are fairly compensated for their services, they can focus on meeting the needs of their patients without undue financial stress.
• Enhanced practice management: Utilizing billing units allows healthcare providers to track and analyze billing data more effectively. This information can identify trends, optimize resource allocation, and make informed decisions about practice management and growth strategies.

What is the 8-minute rule?

The "8-minute rule" is a guideline established by Medicare that governs the billing of timed physical therapy services. It states that for a particular timed service to be considered billable, the total duration of the service provided must meet or exceed 8 minutes. Additionally, if multiple timed services are provided during a single session, they can be combined to determine whether each service meets the minimum threshold for billing.

Here are some instances in which the 8-minute rule works:

• During a physical therapy session, a therapist provides therapeutic exercises for a patient's lower extremities for 12 minutes. According to the 8-minute rule, because the duration of the service exceeds 8 minutes, the therapist can bill for one unit of therapeutic exercise.
• In another session, the therapist provides therapeutic ultrasound for 6 minutes and manual therapy for 7 minutes. While neither service alone meets the 8-minute threshold, the total combined time for both services is 13 minutes so that the therapist can bill for one unit each of therapeutic ultrasound and manual therapy.
• During a session, the therapist provides neuromuscular reeducation for 10 minutes and therapeutic activities for 5 minutes. Even though the total duration of the services offered exceeds 8 minutes, the therapist can only bill for one unit with the highest duration, neuromuscular reeducation, in this case.

It's important to note that the 8-minute rule applies specifically to Medicare billing guidelines for outpatient therapy services. Other payers may have their own rules or guidelines for billing timed services. Additionally, documentation of each service's actual start and stop times is crucial to ensure compliance with the 8-minute rule and accurate billing.

Physical therapy billing process tips

To optimize the physical therapy billing process, the following tips might help:

• Accurate documentation: Proper documentation is critical for successful billing. Ensure that all services provided during therapy sessions are accurately documented, including the type of therapy, duration, and any relevant patient information. Accurate documentation helps support the medical necessity of services and reduces the risk of claim denials.
• Stay updated with coding changes: Keep abreast of changes to billing codes, regulations, and payer policies. Regularly review updates from organizations such as the American Physical Therapy Association (APTA), Centers for Medicare & Medicaid Services (CMS), and private insurance companies to ensure compliance with current coding and billing guidelines.
• Verify insurance coverage: Before initiating therapy services, verify the patient's insurance coverage and eligibility. Confirm that the patient's insurance plan covers physical therapy services and determine any limitations or requirements for reimbursement. This helps prevent surprises and ensures that patients understand their financial responsibility.
• Utilize practice management software: Invest in reliable physical therapy billing software. These software solutions often include features such as electronic billing, claims management, appointment scheduling, and reporting tools. Leveraging technology can streamline the billing process, reduce errors, and improve efficiency.
• Educate staff on billing procedures: Ensure that all staff members involved in the billing process, including therapists, administrative staff, and billing specialists, are adequately trained on billing procedures and compliance requirements. Provide ongoing education and updates on changes to billing codes and regulations to maintain accuracy and consistency in billing practices.

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