Physical therapy billing services.
Every unit backed by the note.

What’s commonly billed

• Evaluations and re-evaluations: physical therapy (97161–97164), occupational therapy (97165–97168) and speech-language evaluations (92521–92524). These are untimed and billed once per visit.
• Timed treatment codes, billed in 15-minute units, such as 97110, 97112, 97116, 97140 and 97530.
• Supervised modalities, which are untimed. Medicare uses its own HCPCS code, G0283, for unattended electrical stimulation instead of 97014.

Payers bundle some pairs of therapy codes, so a second service in the same visit needs to be documented as separate.

The 8-minute rule for Medicare timed codes

CMS bills Medicare timed codes in 15-minute units, counted from the total minutes of timed treatment in the visit. One unit needs at least 8 minutes, and each further unit needs another 15: 8 to 22 minutes is one unit, 23 to 37 minutes is two, and so on. The minutes of all timed services are added together first, then the units are assigned to the services. Untimed codes don’t count toward the total. Other payers may count differently.

Therapy modifiers and the KX threshold

• GP, GO and GN mark a service as physical therapy, occupational therapy or speech-language pathology, under that discipline’s plan of care. Medicare requires them on every therapy line.
• CQ and CO mark services furnished in whole or in part by a physical therapist assistant or an occupational therapy assistant. Medicare pays these services at a reduced rate.
• KX applies once a patient’s therapy for the year passes Medicare’s threshold amount, which is set separately for physical and speech therapy combined and for occupational therapy. It attests that the services are medically necessary and that the record shows it. Above a higher level, claims can be selected for medical review.
• 59 or an X modifier applies only when two services that are normally bundled were truly separate, and the note shows why.

Plan of care and certification

Medicare pays for outpatient therapy furnished under a written plan of care. A physician or other qualified practitioner certifies the plan by signing and dating it, as soon as possible and within 30 days of the first treatment. The plan is recertified when it changes significantly and at least every 90 days. A progress report is due at least once every 10 treatment days. Direct access under state law doesn’t remove Medicare’s certification requirement.

Documentation payers expect

• Minutes for each timed service and the total treatment time.
• What was done, and why it needed a therapist’s skill.
• Progress toward measurable functional goals.
• The evaluation, with the elements that support its complexity.
• A signed plan of care, and recertifications on time.
• Referrals, authorizations and visit counts where the payer requires them.

Common denials, in plain English

• Units that don’t match the minutes in the note.
• A therapy line without its GP, GO or GN modifier.
• Therapy over the threshold billed without KX, or with KX but without a record that supports it.
• A plan of care that was never certified, or a recertification that lapsed.
• Visits past an authorization or a plan’s visit limit.
• Bundled code pairs billed without a documented reason.
• Notes that don’t show why a service needed a therapist’s skill.

How Highview handles it

We check coverage details before claims go out, prepare claims with attention to coding, documentation and each payer’s requirements, and submit and follow up on them. We work denied and rejected therapy claims through correction, resubmission and appeal, post payments and reconcile them, follow up on aging therapy balances, and report on denial trends and outstanding balances so you can see what’s holding claims up.