Physical therapy CPT codes

Physical therapy CPT codes, CPT codes for physical therapy

Physical therapy CPT codes are probably ‘not’ what drew you to PT. The opportunity to help people and a love for the resilience of the human body were probably motivators for you to practice in the profession. While treating may be your favorite part of being a PT, whether you are a solo practice owner, an employee of a physical therapy practice or a manager at a multi-therapist clinic, at some point you must learn the ins and outs of physical therapy CPT codes if you expect to get paid. 

CPT stands for current procedural terminology codes. Physical therapy CPT codes are utilized to describe the services rendered when submitting a claim to a third-party payer. A therapist will select physical therapy CPT codes based on the type of interventions they used and for the amount of time they administered that intervention. These codes provide healthcare providers a uniform language of coding for medical services and procedures.

You may be familiar with some of these common physical therapy CPT codes:

CPT Code

Name 

Descriptor 

97110

Therapeutic exercise

Timed code. Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength, ROM, endurance, and flexibility and must be direct contact time with the patient. 

97112

Neuromuscular re-education

Timed code. Therapeutic procedure, one or more areas, each 15 minutes; activities that facilitate movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. Therapeutic taping or other inhibition/facilitation techniques fit in this category.

97116

Gait training

Skilled improvement of gait, including stair training. Focuses on the biomechanics of gait. Walking exercises to improve endurance or cardiovascular health would not go in this category. 

97140

Manual therapy

Timed code. Skilled hand movements and passive movements of the joints and soft tissue intended to improve tissue extensibility; increase range of motion; induce relaxation; mobilize or manipulate soft tissue and joints; modulate pain; and reduce soft tissue swelling. Includes soft tissue mobilization, joint mobilization, manipulation, manual traction, muscle energy techniques (performed using resistance applied by PT), and manual lymphatic drainage. PROM is not manual therapy.

97530

Therapeutic activity

Timed code. Dynamic activities used to promote improved function. Typically utilize multiple parameters such as strength, range of motion, motor control, balance, endurance, etc. Sit to stands, transfers, bed mobility or sport-specific training may fall in this category. 

97535

Self-care/Home management training

Instruction on compensatory training and in use of adaptive equipment, on ADLs, meal prep and safety procedures. Can also include instruction on wound care, use of a home TENS or electrical stimulation unit, strategies for edema control, advice on sleeping positions, and even transfer training. As long as you are addressing basic ADLs in your plan of care (eating, bathing, dressing, toileting, transferring and continence) you can bill this code. Instruction in a home exercise program should be billed under Therapeutic Exercise. 

97750

Physical performance test or measurement 

Used to bill for functional capacity exams, isokinetic testing and some specific tests and measures related to balance like the Timed Up and Go. This is a timed code and it is not medically reasonable and necessary to bill this service as part of a routine assessment/evaluation of rehabilitation services

97161

Low Complexity Evaluation

PT history includes no comorbidities or personal factors impacting the plan of care. Plan of care addresses 1-2  elements of body structure/function, activity and/or participation restrictions. The clinical presentation is stable. Untimed Code.

97162

Moderate Complexity Evaluation

PT history includes 1-2 comorbidities or personal factors impacting the plan of care. Plan of care addresses 3 or more elements of body structure/function, activity and/or participation restrictions. The clinical presentation is evolving. Untimed Code. 

97163

High Complexity Evaluation

PT history includes 3 or more comorbidities or personal factors impacting the plan of care. Plan of care addresses 4 or more elements of body structure/function, activity and/or participation restrictions. The clinical presentation is unstable. Untimed Code. 

97164

Physical therapy re-evaluation

Requires an examination and a revised plan of care.


Most physical therapy billing codes are described in terms of 15-minute units of service. It is critical to review your payer policy to determine how to bill for timed units. If they utilize the 8-Minute Rule for billing outlined by Medicare then at least at least 8 minutes of a single intervention must be administered to bill for one CPT unit, 23 minutes for 2 units of that service, 38 minutes for 3 units and 53 minutes for 4 units of that service. Alternatively, on page XVII of the 2021 CPT manual under the section entitled time, guidance is provided for billing a single unit of timed service once you have passed the midpoint of a 15-minute block. In other words if 7 minutes and 30 seconds of service has been provided then you can bill for one timed unit and it does not stipulate that you must add a certain number of minutes to bill more than one unit.

All physical therapy CPT codes are five digits and are either numeric or alphanumeric. Most of the physical therapy CPT coding falls into the 97000 series called Physical Medicine and Rehabilitation. It is important, however, to be familiar with relevant codes outside of this series because a provider can use any of the physical therapy CPT codes as long as it accurately describes the services provided and is allowed under their state licensure laws. 

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Physical therapy CPT codes are often undergoing revisions both on the editorial side and the value side so it is important to reference timely physical therapy CPT codes resources such as the American Medical Association, which actually owns the copyright of the physical therapy CPT codes. Additionally, it is important to understand that while a provider may be allowed to utilize certain physical therapy CPT codes, it may or may not be reimbursed by a given payer depending on their individual payment policy.  

Physical therapy billing

Physical therapy CPT codes are an important part of the billing process. After providing a service, documenting and signing the treatment note, and selecting the appropriate physical therapy CPT codes, a bill will be submitted to the patient, a third party payer or to a claims clearinghouse that will act as a middleman between the therapist or business and the payer.

When submitting physical therapy CPT codes for billing, it is important to be aware of several modifier codes that may be necessary to include. 

  • Modifier 59: According to the CMS website, the CPT manual defines Modifier 59 as follows: “Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances … Modifier 59 is used appropriately for two services described by timed codes provided during the same encounter only when they are performed sequentially. There is an appropriate use for Modifier 59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If two timed services are provided in blocks of time that are separate and distinct (i.e., the same time block is not used to determine the unit of service for both codes), Modifier 59 may be used to identify the services.”


Examples: 

  • 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 (use of dynamic activities to improve functional performance), each 15 minutes

“Modifier 59 may be reported if the two procedures are performed in distinctly different 15 minute time blocks. For example, one service may be performed during the initial 15 minutes of therapy and the other service performed during the second 15 minutes of therapy. Alternatively, the therapy time blocks may be split. For example, manual therapy might be performed for 10 minutes, followed by 15 minutes of therapeutic activities, followed by another 5 minutes of manual therapy. CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same time block.” 

  • Modifiers XE, XS, XP, XU: Effective January 1, 2015, these modifiers were developed to provide greater reporting specificity in situations where Modifier 59 was previously reported and may be utilized in lieu of Modifier 59 whenever possible. These codes are used to indicate a separate encounter (XE), separate structure (XS), separate practitioner (XP), and unusual, non-overlapping service (XU). 

  • Modifier GP: When submitting an outpatient physical therapy claim it must include the modifier GP which indicates that these services were provided under a physical therapy plan of care.

  • KX Modifier: As of 2018 the Medicare physical therapy cap acts as a threshold after which a physical therapist continuing to provide service to a patient must attach a KX Modifier to their billing to indicate medically necessary services. Documentation must justify that continued services are medically necessary. As of 2021, a KX modifier must be applied as soon as incurred expenses exceed $2,110 for physical therapy and speech therapy services combined. 

While paper claims are still available and in use, most providers are moving toward electronic claims forms. The Universal Claim form CMS-1500 is the most common but payers may also provide their own forms.



Electronic claims are submitted to the payer or to the claims clearinghouse. These claims are covered under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and are required to meet certain standards. When submitting a claim it is important to review the information to ensure it is “clean.” A clean claim, whether paper or electronic means that it is accurate, complete, and legible (if a paper claim).  

While this information has hopefully helped make you feel more comfortable with physical therapy CPT codes and billing for your practice, there is still a lot to learn and a lot on the line if coding and billing are done incorrectly.  

Resources

When looking to streamline and error-proof your physical therapy CPT codes and billing practices, an EHR, practice management and teletherapy tool such as Theraplatform simplifies billing and payment tracking with flexible invoicing, superbills, claim tracking and insurance integrations. As physical therapy CPT codes, modifiers and billing regulations continue to evolve and change each year to keep up with an evolving healthcare landscape, Theraplatform will give you the confidence you need to keep building your practice. They also offer a free, 30-day trial with no credit card required. Cancel anytime.

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Modifier 59

While billing and claim submission are not fun, learning about effective billing practices including how to use Modifier 59, can keep your practice profitable.

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