Physical therapy billing
Physical therapy billing helps keep the lights on in the clinic, pays the staff and helps when it comes to purchasing new equipment. And it is through timely and accurate billing practices that these costs get covered. Whether you are a staff therapist, a physical therapy manager or support staff in charge of billing and insurance verification, it is a good idea to understand the physical therapy billing process.
In this article you will learn about the steps of physical therapy billing including verifying insurance benefits, documenting and selecting CPT codes, submitting claims to insurance companies, posting and reconciling payments and preparing for claims audits. Finally, you will learn how the right EHR/EMR software system can take the stress out of billing for physical therapy.
Insurance coverage and verification for physical therapy services
The first step in physical therapy billing is verifying a client’s insurance benefits for physical therapy.
Following these steps can help smooth the process of insurance verification.
Step 1: Gather details about the patient and policy holder
- Collect patient details including name and date of birth
- Ask if they are the primary policy holder and if they are not, gather the name and date of birth of that person and their relationship to the patient
Step 2: Gather details about the insurance plan
- Collect the name, address and phone number of the insurance carrier from the back of their card
- Write down the policy number and group number
Step 3: Prepare a list of CPT and ICD-10 codes relevant for the patient and their treatment
** If the patient has a secondary insurance, repeat steps 1-3 for this policy as well
Step 4: Verify the benefits by contacting the insurance company.
The easiest way to do this is through electronic benefits authorization (EBA). Though not all insurance companies provide this option, those that do typically have an online portal on their website specifically for providers to search for members in order to check eligibility and benefits. If EBA is not an option, be prepared to pick up the phone and make a call to the insurance company. It is always a good idea to verify that the person who answers the phone is the right person to answer your questions.
When checking benefits for physical therapy billing, it is best to get all of the information at one time so preparing a list like the one below can help ensure you don’t miss anything important.
- How many physical therapy visits is the patient allowed per year?
- How many of these visits do they have left to use for the rest of the policy year?
- Is there a hard limit on visits or can more visits be requested? What is the process for doing so?
- When is their policy end date?
- Is a physician referral, pre-authorization or evidence of medical necessity needed prior to commencing care or at any interval during their care?
- Is the clinic/therapist that the patient will be working with in-network or out-of-network?
- Does the patient have a copay? How much is the copay?
- For multidisciplinary visits in which a patient is receiving PT and OT in one day, for example, do they need to pay separate co-pays or only one co-pay?
- Does the patient have a deductible, what is it and how much of it have they already met?
- Are there any limitations or other requirements that must be fulfilled prior to the patient’s first visit?
Documentation and CPT codes for physical therapy billing
Now that you know how many visits a patient has available and what services are covered by the insurance plan, care can begin. Reimbursement for physical therapy services requires accurate documentation of services provided along with the submission of CPT codes, also known as Common Procedural Technology codes, that match those services. Your documentation needs to outline the exact treatment provided during 27 minutes or two units of therapeutic exercise, for example, along with the rest of the time spent treating or assessing. This helps guard against claim denials and fraudulent physical therapy billing practices. A list of common CPT codes can be found below. See specifics on CPT codes here and units for billing here.
Self-Care/Home Management training
Physical Performance Test or Measurement
Physical Therapy Re-evaluation
Submitting claims to insurance for physical therapy billing
Once a therapist has completed their documentation which includes the appropriate physical therapy billing ICD-10 and CPT codes and appropriate modifiers, the information is submitted to a biller in order to generate a claim form. Most claims are now electronic, though paper claim forms are still used in some cases. The Universal Claim form CMS-1500 is the most common but payers may also provide their own forms. Having billing software integrated with your EMR/EHR software makes this process much easier.
Electronic claims are submitted to a claims clearinghouse which acts as a middleman between the therapist or business and the payer. 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). Once the clearinghouse has verified the claim is clean, they will submit it to the insurance company. If they notice missing information they will “reject” the claim and send it back to the therapist to addend or correct.
Payment posting and reconciliation for physical therapy billing
Once the insurance company auditor receives the claim, they will determine how much the company will reimburse for the therapy services and send a check or direct deposit to the therapy clinic or therapist which should then get entered or “posted” into the clinic’s accounting system. If the insurance company finds that the therapist billed for an uncovered service, failed to apply the correct modifier or utilized the wrong codes, they may issue a denial of payment. At the same time, the insurance company will send an Explanation of Benefits (EOB) to the patient which outlines what portion of the services they covered and what the patient will owe.
The final step in this process is payment reconciliation in which the clinic determines what the patient will owe them for the services provided and then bills the patient directly for the remaining balance. Underpayments, overpayments, denial of payment and previous patient balances are all important pieces of the reconciliation process.
Claims audits in physical therapy billing
Claims audits are becoming more common in rehabilitation. Billing fraud and abuse is a serious concern and claims audits are used to help curb this practice. Understanding some common triggers of a claims audit can help reduce the likelihood of an audit and help ensure you are billing appropriately.
Some practices that can trigger an audit are:
- Noncompliance with the Medicare 8-minute rule and/or CCI edits
- Excessive use of the KX modifier (above the norm)
- Missing certifications in the plan of care
- Missing physician signatures
- Failure to recertify the plan of care when necessary
- Insufficient documentation
- Post-denial modification to documentation
- Noncompliance with frequency/duration rules indicated within local coverage decision (LCD)
- Failure to supply records to Medicare when requested
- Billing for individual therapy when group therapy was actually provided
- Failing to execute an ABN and instead billing Medicare falsely under the guide of Medical Necessity
- Billing for duration and frequency outside the norm of care
- Failing to provide evidence of medical necessity for covered services
One way to limit the impact of a claims audit in physical therapy billing is to set up a system of regularly auditing charts within your clinic. This can help identify issues as they arise and provide opportunities to make changes and improvements sooner rather than later. Utilizing the CMS guide to Outpatient Rehabilitation Documentation can be very helpful. The Centers for Medicare and Medicaid Services also provides a checklist to help you respond to and prepare for an audit.
The right EHR/EMR software can make physical therapy billing easier
Having the right EHR/EMR software can help simplify physical therapy billing, help you maximize reimbursements and earn more. A system like TheraPlatform, an all-in-one EHR, practice management and teletherapy tool, can catch common errors on claims before they get submitted. They can automatically create and submit batch claims on a regular, set date. Automatic posting and reconciliation of payments helps you get your payments more quickly.
They also offer a free 30-day trial without a credit card required. Cancel anytime.
- The 8-minute rule
- PT billing units
- Physical therapy CPT codes
- Electronic claims submissions
- 8-minute rule
- Therapy resources and worksheets
- Therapy private practice courses
- Ultimate teletherapy ebook
- The Ultimate Insurance Billing Guide for Therapists
- The Ultimate Guide to Starting a Private Therapy Practice