Orthopedic surgeons are increasingly incorporating physical and occupational therapy services into their practices. In-house billers, who may be inexperienced with the new services, terminology, and associated CPT codes, may be unsure about billing for therapy care. MedicalBillersandCoders (MBC) is a leading medical billing company providing complete revenue cycle services. We keep on sharing billing and coding guidelines, updates, and industry news, to assist providers and the in-house billing team. This article can be treated as a beginner’s guide for billing therapy care.
Billing Therapy Care
Understanding the billing terms and the chronology of therapy care is key to appropriate therapy billing. We reviewed, Medicare coverage guidelines, which are often used by other insurance carriers as well, are outlined in Chapter 15, section 220, of the Medicare Benefit Policy Manual. Although Medicare allows qualified nonphysician providers to order and certify therapy services, this focus is on physicians as the ordering entities. Therapy treatment begins with a physician order or referral, which includes a diagnosis and may include directions for the type, duration, and intervals of treatment.
- As a first step, the therapist performs an evaluation to define a plan of care, which builds on the physician’s order and details the patient’s long-term treatment goals and the therapy services planned. Re-evaluation may be needed when the plan of care or patient’s status changes and maybe reportable using a re-evaluation code. Medicare has a CCI edit between re-evaluation and several modalities and therapeutic procedures and requires the use of modifier -59 when both services are supported and documented.
- Medicare guidelines call for the ordering physician to approve or certify, the plan of care via a signature in a timely manner (within 30 days of the evaluation). The initial certification covers 90 days or less of treatment, after which the plan of care must be recertified.
- When setting up therapy services, practices should ensure the certification process works properly. Don’t rely on your electronic medical record (EMR) system to relay the plan of care to the physician for certification without testing it first.
- Treatment may begin on the day the plan of care is set. The treatment notes describe the patient’s care at each visit (e.g., modalities and therapeutic procedures). Documentation should include an assessment of improvement, modifications to the patient’s goals, and both timed code minutes and total time with the patient. Interventions and modalities should be documented in terms that correspond with billing codes.
- Medicare requires that the therapist provide a progress report for the ordering provider after the 10th treatment encounter, or within 30 calendar days of the first treatment, whichever is less. The therapist may include elements of the progress report within the treatment notes or a revised plan of care.
- At the conclusion of the therapy episode, the therapist will prepare a discharge note that details the patient’s treatment and status since the last progress note. Writing the progress report and discharge note are not separately billable services for the therapist but are required for Medicare documentation.
- Selected therapy services may be performed by a therapy assistant under the supervision of a therapist. Review your state guidelines and the Medicare Benefit Policy Manual for additional information.
- Medical necessity is an essential element of therapy services. Medicare carriers may establish unique local carrier determination (LCD) policies for the medical necessity that affect reimbursement. You can refer to the insurance carrier’s website for LCD policy information.
- Practices typically rely on the therapist or assistant to document required time elements within a progress note or EMR system. Billing staff may use the documentation to confirm the number of service units reported.
- Note that, providers should not bill for services performed for less than 8 minutes when only one service is administered in a day. Time intervals are assigned in increments of 15 minutes, beginning with a base of at least 8 minutes (1 unit is ≥ 8–22 minutes; 2 units are ≥ 23–37 minutes; 3 units are ≥ 38–52 minutes, etc.). When more than one service represented by 15-minute timed codes is performed in a single day, the total minutes of service determines the number of timed units billed.
Most of the times providers or small group practice owners prefer to handle medical billing operations all on their own. We hope that the above-mentioned guidelines will help them and their in-house billing staff inaccurate billing for therapy care. If you need assistance in medical billing for your practice, then -contact us at info@medicalbillersandcoders.com/ 888-357-3226.
FAQs
1. What are the steps in therapy care billing?
Therapy billing starts with a physician’s order, followed by an evaluation, plan of care certification, treatment notes, progress reports, and a discharge note.
2. How is therapy time billed?
Therapy is billed in 15-minute increments:
- 1 unit: 8–22 minutes
- 2 units: 23–37 minutes
- 3 units: 38–52 minutes
Services under 8 minutes aren’t billable.
3. What documentation is needed for therapy billing?
Include treatment notes, progress reports (after 10 visits or 30 days), and discharge notes. Medicare also requires plan certifications.
4. When are modifiers like -59 used?
Modifiers are applied to show distinct services, such as billing re-evaluations with other procedures, ensuring proper reimbursement.
5. Why is medical necessity important?
Document medical necessity per insurer policies (e.g., LCDs) to avoid claim denials and ensure proper reimbursement.
