Physical Therapy CPT Codes and the Medicare 8 Minute Rule in Physical Therapy Billing

Physical Therapy CPT Codes and the Medicare 8 Minute Rule in Physical Therapy Billing

Let’s understand our Physical Therapy CPT Codes and the 8 Minute Rule Physical Therapy Billing based on Medicare’s Guideline.

There are 2 types of Physical Therapy Modalities

Constant Attendance Modality

Constant Attendance Modality (billed in 15 minutes increments) – REQUIRES direct one-on-
one provider to patient contact.

97032 – Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
97033 – Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
97035 – Application of a modality to 1 or more areas; ultrasound, each 15 minutes
97039 – Unlisted modality (specify type and time if constant attendance)

Supervised Physical Therapy Modality.

  1. Supervised Modality (billed one unit per date of service, regardless of number of anatomical
    body areas)

DO NOT REQUIRE direct one-on-one provider to patient contact.

97010 – Application of a modality to 1 or more areas; hot or cold packs
97012 – Application of a modality to 1 or more areas; traction, mechanical
97014 – Application of a modality to 1 or more areas; electrical stimulation (unattended)
** CMS code G0283 – Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care

97024 – Application of a modality to 1 or more areas; diathermy (eg, microwave)
97026 – Application of a modality to 1 or more areas; infrared
97028 – Application of a modality to 1 or more areas; ultraviolet

Physical Therapy Therapeutic Procedures CPT Codes

Then you have the physical therapy therapeutic procedures; this is time-based! one or more areas, each 15
minutes) -Watch the 8 Minute Rule for Physical Therapy Billing!

  • CPT Code 97110 – Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
  • CPT Code 97112 – Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
  • CPT Code 97116 – Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)
  • CPT Code 97124 – Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
  • CPT Code 97139 – Unlisted therapeutic procedure (specify)
  • CPT Code 97140 – Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes
  • CPT Code 97530 – Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
Practice Management Therapists

How to calculate the 8 Minute Rule for Physical Therapy Billing and Coding

1 unit ≥ 8 minutes through 22 minutes (total)
2 units ≥ 23 minutes through 37 minutes (total)
3 units ≥ 38 minutes through 52 minutes (total)
4 units ≥ 53 minutes through 67 minutes (total)
5 units ≥ 68 minutes through 82 minutes (total)
6 units ≥ 83 minutes through 97 minutes (total)
7 units ≥ 98 minutes through 112 minutes (total)
8 units ≥ 113 minutes through 127 minutes (total)

*** less than 8 minutes is not billable if only one time-based code is used on thesame date of service or on the same day
*** for one time-based code performed in 15 minutes must be billed as 1 unit from looking at the rule (8-22 minutes equals 1 unit!)

Let’s do the Math:

->Get the total minutes for all time-based therapy codes:

97110 for 32 minutes
97140 for 12 minutes
== TOTAL MINUTES is 44 minutes (go back to the chart, 44 minutes is 3 units!)

BILL 97110 for 2 units and 97140 for 1 unit

Another Example:

97124 for 10 minutes
97110 for 16 minutes
97140 for 29 minutes
== TOTAL MINUTES is 55 minutes (go back to the chart, 55 minutes is 4 units!)

BILL 97140 for 2 units 97110 for 1 unit and 97124 for 1 unit

Look at these examples as given by CMS: Pub 100-04 MCR Claims Processing Transmittal 2121 CR 7247 12-17-2010 R2121CP

Pub. 100-02, chapter 15, section 230.3B

“Treatment Notes indicates that the amount of time for each specific intervention/modality provided to the patient is not required to be documented in the Treatment Note. However, the total number of timed minutes must be documented. These examples indicate how to count the appropriate number of units for the total therapy minutes provided.”

Scenario Example 1
24 minutes of neuromuscular reeducation, code 97112,
23 minutes of therapeutic exercise, code 97110,
Total timed code treatment time was 47 minutes.

See the chart above. The 47 minutes falls within the range for 3 units = 38 to 52 minutes.

Appropriate billing for 47 minutes is only 3 timed units. Each of the codes is performed for more than 15 minutes, so each shall be billed for at least 1 unit. The correct coding is 2 units of code 97112 and one unit of code 97110, assigning more timed units to the service that took the most time.

Scenario Example 2
20 minutes of neuromuscular reeducation (97112)
20 minutes therapeutic exercise (97110),
40 Total timed code minutes.

Appropriate billing for 40 minutes is 3 units. Each service was done at least 15 minutes and should be billed for at least one unit, but the total allows 3 units. Since the time for each service is the same, choose either code for 2 units and bill the other for 1 unit. Do not bill 3 units for either one of the codes.

Scenario Example 3
33 minutes of therapeutic exercise (97110),
7 minutes of manual therapy (97140),
40 Total timed minutes

Appropriate billing for 40 minutes is for 3 units. Bill 2 units of 97110 and 1 unit of 97140. Count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.

Scenario Example 4
18 minutes of therapeutic exercise (97110),
13 minutes of manual therapy (97140),
10 minutes of gait training (97116),
8 minutes of ultrasound (97035),
49 Total timed minutes

Appropriate billing is for 3 units. Bill the procedures you spent the most time providing. Bill 1 unit each of 97110, 97116, and 97140. You are unable to bill for the ultrasound because the total time of timed units that can be billed is constrained by the total timed code treatment minutes (i.e., you may not bill 4 units for less than 53 minutes regardless of how many services were performed).
You would still document the ultrasound in the treatment notes.

Scenario Example 5
7 minutes of neuromuscular reeducation (97112)
7 minutes therapeutic exercise (97110)
7 minutes manual therapy (97140)
21 Total timed minutes

Appropriate billing is for one unit. The qualified professional ( See definition in Pub 100-02/15, sec. 220) shall select one appropriate CPT code (97112, 97110, 97140) to bill since each unit was performed for the same amount of time and only one unit is
allowed.

So how about the 2017 New Physical Therapy Evaluation Codes – let’s see here.

Key Points you need to remember:

  1. Each of these codes are not “time-based”; typical time is used as a guidance only
  2. Complexity (low-medium-high)
  3. Therapy Evaluation encounter MUST meet Medical Necessity and clearly documents FUNCTION
  4. Use these new therapy evaluation codes for Medicare and commercial payers; Workers’ Comp and MVA liability may still be using 97001/97002
  5. CPT Code 97001 is DELETED and REPLACED by 3 new physical therapy evaluation Codes
  6. CPT Code 97002 is DELETED and REPLACED by one single re-evaluation code

These New Physical Therapy Evaluation Codes has (very important to take note)

4 Components of Complexity and Severity:

  1. Patient Medical and Functional HISTORY, which includes relevant comorbities and personal factors;
    • Comorbities/pre existing conditions that affects function and ability to progress through a plan of care
    • History of Functional limitation(s) and level; current functional level, abilities and limitations
    • Identify and Document Personal Factors that may impact the plan of care for Physical Therapy treatment; eg. age, gender, social history, education background, lifestyle, coping styles, job/profession, present/past experience. Document the overall behavior patterns including experience with disability
      • Existing personal factors that will not impact the plan of care should not be used when selecting the level of service
  2. Examination of body system(s) using standardized tests and measures;
    • Body Structures: Anatomical or structural parts of the body, eg., the organs, limbs and their components, classified according to the body systems;
    • Body Regions: Includes the Head, neck, back, lower extremities, upper extremities and trunk
    • Body Systems:
      • Musculoskeletal (range of motions, strength, weight/height, symmetry)
      • Neuromuscular (coordinated physical/body movement which includes gait transfers, locomotion and transitions) and motor functions on control and learning
      • Cardiovascular Pulmonary (RR, HR, BP and Edema)
      • Integumentary (skin integrity, texture, presence of scar formation)
    • Review of Systems should also include orientation of person, place and time; consciousness, the ability to express/show needs, anticipated emotional and or behahavioral responses
  3. Clinical Presentation of the patient
    • Stable and uncomplicated, OR
    • Evolving clinical presentation with changing clinical characteristics OR
    • Evolving clinical presentation with unstable and unpredictable characteristics
  4. Clinical Decision Making (based including the utilization of standardized patient assessment tools and or using the Functional Outcome measurable assessment result

The codes are based in large part on the amount of time and complexity involved in the evaluation. See below identifies the new physical therapy codes for 2017 and gives the long-form description of each code.

2017 New Physical Therapy Evaluation Codes – here are your codes!

CPT Code 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 system(s) 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; and
  • Clinical decision-making of low complexity using a standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.

CPT Code 97162

Physical therapy evaluation: moderate complexity, requiring these components:

  • A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;
  • An examination of body systems using standardized tests and measures in addressing a total of three or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
  • An evolving clinical presentation with changing characteristics; and
  • Clinical decision-making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family.

CPT Code 97163

Physical therapy evaluation: high complexity, requiring these components:

  • A history of present problem with three or more personal factors and/or comorbidities that impact the plan of care;
  • An examination of body systems using standardized tests and measures addressing a total of four or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
  • A clinical presentation with unstable and unpredictable characteristics; and
  • Clinical decision-making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family.

2017 New Physical Therapy Codes for Re-Evaluation

CPT Code 97164

Re-evaluation of physical therapy, established plan of care, requiring these components:
An examination, including a review of history and use of standardized tests and measures is required; as is a
Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.

These new codes are all untimed codes, and when recording time for Medicare, the minutes allocated for the evaluation are tallied as part of the “total treatment minutes,” which includes timed codes and untimed codes.

Since these codes are untimed codes, the time (minutes) rendered during the evaluation are now part of the “total minutes” of treatment time – this includes both the untimed and timed codes.

How about the CMS Reimbursement?

The 3 New Physical Therapy Evaluation codes are being reported based on its Complexity, they are priced based on a group than per code. Reimbursement is the same on each level/code.

Additional guiding factors include coordination, consultation, and collaboration of care consistent with the nature of the problem and the needs of the patient. I always recommend to never miss reporting a referring physician on Box 17 of the HCFA 1500 claim form.

READ MORE: CMS Therapy Guidelines, Policies and Updates https://www.cms.gov/Medicare/Billing/TherapyServices/index.html

CPT is owned and a trademark of the American Medical Association

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