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Medicare vs. Non-Medicare: Reporting CPT Codes When Providing Physical Therapy Services

Last Updated Nov 2012


By: OptimisPT

physical therapy servicesTraveling around the country and working with hundreds of therapists every year, there is one question that is frequently asked regarding coding for Medicare vs. non-Medicare patients: “Do I need to follow the same rules for CPT coding related to direct contact and the provision of one-on-one physical therapy services to non-Medicare patients that are required under the Medicare Program?” The answer, simply, is yes!

Providers of physical therapy services who bill non-Medicare payers and report their services using the CPT codes are bound by the definition of the CPT codes as published and copyrighted by the American Medical Association. The CPT system is not a Medicare specific coding system, so therapists should not fall into the trap of thinking there is one set of CPT coding rules related to Medicare and a different set of coding rules that apply to non-Medicare payers. It is important to keep in mind that coding for a service is separate than payment for a service. A common misperception is that therapists need to code their services describing their treatment to Medicare patients one way, while coding for physical therapy services provided to non-Medicare patients differently. Putting this misperception into practice can place physical therapists that do so in a position of risk related to the possible submission of a false claim or adverse effects of a payer audit.

medicare patientsAs an example, the description for the CPT code Therapeutic Exercise, 97110, states: “Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength, endurance, range of motion and flexibility”. While a physical therapist (PT) or physical therapist assistant (PTA) may read this and interpret that the service descriptor does not include any reference to the need for “direct (one on one) contact” in order to support the reporting of this code, providers need to be aware of how to read, interpret and apply the CPT codes in order to be compliant with any specific payer policy. The preamble of the Therapeutic Procedures section of the 97000 series includes the following language related to the codes listed in this section of CPT1:

“Therapeutic Procedures: A manner of effecting change through the application of clinical skills and/or services that attempt to improve function. Physician or therapist required to have direct (one on one) patient contact”.

This preamble applies to the codes printed below it in the CPT manual. CPT code 97110, describing therapeutic exercise, therefore, includes the requirement for “direct (one on one) patient contact”.

There is currently no CPT code to describe “supervised” exercises in which the PT or PTA is overseeing the service but not providing direct, one on one contact with one patient at a time. This inability to code for supervised services has no relationship to the ability to have one or more patients in the facility during any part of the day and clinic’s hours of service. Coding should all be done from the perspective of the therapist and the services they are providing to their patients, not from the perspective of the patient and who is sharing the clinic's services.

Specifically, the PT or PTA should be coding for the skilled intervention they are providing to the patient that requires their knowledge and expertise, and not coding and billing for situations in which the patient is performing exercises “on their own” or with only occasional supervision by the provider.

Most importantly, therapists should be aware that this coding advice is based on the correct interpretation of the CPT codes and applying the codes accurately when describing clinical services. CPT code 97110 has been an example used to help convey this information but there are other CPT codes that also require direct (one on one) contact with the patient, regardless of cpt codeswhether the physical therapy services are being submitted to Medicare or non-Medicare payers. State law and third party payers may provide for additional requirements and specific payment policy related to the reporting of CPT codes, and providers should be certain to follow those requirements, in addition to all applicable CPT rules.

Reference:

1AMA Current Procedural Terminology (CPT) Copyright, 2009, Professional Edition

About the Authors: Ms. Helene Fearon and Dr. Stephen Levine are partners in Fearon & Levine, and additional information on this and other related topics can be accessed at www.FearonLevine.com.

optimisPTOptimisPT is a web-based physical therapy EMR and documentation software that provides complete, evidence-based physical therapy documentation, scheduling, billing, and practice management, to physical therapy practices.

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