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Developed by the American Medical Association (AMA), the Current Procedural Terminology (CPT®) is “the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs.” According to the APTA, “When billing most third parties for services…it is necessary to utilize CPT-4 codes to describe the services that were rendered. Although CPT is not an exact description of physical therapists’ interventions, it does provide a reasonable framework for billing.”
Most of the CPT codes that are relevant to rehab therapists are located in the 97000 section (“Physical Medicine and Rehabilitation”). However, you can bill any code that best represents the service you provide as long as you can legally provide that service under state law. Be forewarned, though: just because you can legally bill for a code doesn’t automatically mean that a payer will reimburse you for it. When in doubt, always check with your payers before providing the service in question.
All physical and occupational therapists should get to know the following CPT categories before billing for their services:
- PT evaluations (97161-97163) and OT evaluations (97165-97167), which are tiered according to complexity:
- 97161: PT evaluation – low complexity
- 97162: PT evaluation – moderate complexity
- 97163: PT evaluation – high complexity
- 97165: OT evaluation – low complexity
- 97166: OT evaluation – moderate complexity
- 97167: OT evaluation – high complexity
- PT re-evaluations (97164) and OT re-evaluations (97168)
- Supervised (untimed) modalities (97010–97028)
- Constant attendance (one-on-one) modalities (97032–97039, which are billable in 15-minute increments)
- Therapeutic (one-on-one) procedures (97110–97546)
- Active wound care management (97597–97606)
- Tests and measurements (97750–97755)
- Orthotic and prosthetic management (97760–97762)
One-on-One Services vs. Group Services
If you’re providing group therapy services, you should not use one-on-one CPT codes, because this can increase your risk of an audit. So, what are one-on-one services? They’re individual therapy services—ones that involve direct, one-on-one contact with a patient. During her Ascend 2015 presentation, Deb Alexander explained that these codes are cumulative, require constant attendance, and are time-based, which—as this article points out—means that the 8-minute rule applies. (See how many units you can bill based on treatment time.)
Now, even if you’re working with more than one patient at a time, you still can provide—and bill for—one-on-one services. That’s because CMS allows these one-on-one minutes to occur continuously or in intervals—as long as those intervals are “of a sufficient length of time to provide the appropriate skilled treatment in accordance with each patient’s plan of care.”
Group therapy still requires constant attendance, but it does not involve one-on-one contact with the patient. Rather, CMS writes that it “consists of simultaneous treatment to two or more patients who may or may not be doing the same activities.” So, if you’re providing attention to more than one patient at a time with only “brief, intermittent personal contact,” you should bill one unit of group therapy to each patient.
To learn more about the differences between billing for one-on-one services and group services, read this article.