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Five Billing Tips For Preventing Physical Therapy Denials


Here are some tips on preventing physical and occupational therapy denials.

As is typical of many specialties, physical therapy (PT) and occupational therapy (OT) have different billing and coding hurdles to overcome. Ensuring defensible documentation is merely part of the job. The other part is knowing the guidelines that payers must follow for time-based reporting. Here are some tips on preventing physical and occupational therapy denials.

Record The Complexity Of Evaluations

CPT codes now specify low, moderate, and high complexity. Because of this, providers have to understand, as well as document, the specific elements that support where they were designated.

The CPT manual helps as a reliable reference point since the descriptions for the new codes includes the various relevant documentation pieces. Also, keep in mind that you may need to upcode more stratified ones. For example, high complexity OT evaluation documentation needs to support an assessment of at least five performance deficits that are limiting the client’s activity. It also has to reflect advanced clinical decision-making. Without all of these pieces, providers might end up facing denials.

Specify Regions Of The Body

To avoid denials, you want to document the exact joints and muscles that were treated. This not only justifies CPT codes requiring therapy on their body but also helps payers to understand each unique injury so that liability can be assigned.

Count Units Of Time Carefully

Denials are more likely to occur if you’re unsure of whether your payer needs providers to add all time-based services together, or if they need to report these codes separately. If you don’t know what your payers are doing, it will be much tougher to get paid for services properly.

You also need to keep in mind that the CPT manual says that a single unit of time happens when the provider passes the midway point for a particular time-based service. For physical and occupational therapy codes, midway is eight minutes.

Knowing When To Apply Modifier-59

Modifier-59 might apply to physical and occupational therapy if the same provider performs two timed procedures at two separate times of the day.

Providers should never bill a time-based code for multiple patients at once unless they can show that the services were done at different individual blocks of time, or with the help of a PT or OT assistant who happens to be a reimbursable provider under the payer’s contract.

Distinguish Between Timed And Untimed Electrical Stimulation

Remember that it’s report 97032 for timed electrical stimulation and report 97014 for untimed electrical stimulation if you want to lower your denials. You can’t get a time-based code unless you document that you were physically in the vicinity for the direct contact of the patient. If you don’t record anything, you will be down-coded to untimed code. You also want to check with your carrier before reporting the codes.

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This entry was posted on Thursday, August 8th, 2019 at 10:35 am. Both comments and pings are currently closed.