Physical therapy billing practices are considerably fragmented in the US with the large number of payers, Medicare, TRICARE, and private payers. Staying on top of billing rules is an uphill task for any therapist. As a result, it is relatively easy to get shortchanged in terms of billing practices.
On one hand, payers are tightening their procedures leading to declining reimbursements and pressure on physical therapy profitability. On the other, several enforcement actions have been reported around practices like simultaneous multi-patient services billed as single patient, upcoding services, and so on.
The need is to accurately document, submit, and track claims, especially when billing payers such as Medicare, Medicaid, or TRICARE. Recommended best practices include:
Accurately reporting service duration in the case of time-based codes.
Reviewing documentation and routinely self-auditing to avoid negative scrutiny.
Ensuring that services are in line with plan of care goals.
Uncovering snowballing documentation problems before they cause liability issues.
This blog takes a closer look at some of the ways that physical therapists could be missing out in their billing.
Physical Therapy Billing for Telehealth Sessions
Many private practices began using telehealth as a way of circumnavigating non-essential contact following the onset of the Covid-19 pandemic. However, billing guidelines for telehealth can vary significantly from in-person care and require additional scrutiny. Mistakes in claim scrubbing could lead to claims getting delayed or even rejected.
Telehealth rules need to be set at the individual payer level as different payers have different rules that they may apply. CPT codes, modifiers, and place of service (POS) codes may differ from payer to payer?the complexities are many. For example, there are three place of service codes for billing virtual care: 02 (Telehealth), 11 (Office), and 12 (Home). POS code 11 applies if patients would normally be treated in outpatient clinics and POS 12 if they would be normally be treated at their homes. Use of the 02 modifier when billing Medicare (or other payers that are providing telehealth payment parity) will trigger pre-Public Health Emergency discounts for telehealth services. Medicare requires PTs and OTs to use HCPCS G-codes for e-visits. While other payers may require HCPCS codes or equivalent 98-series CPT codes.
Physical Therapy Claim Tracking and Denial Management
Physical therapy offices often send out dozens or more claims every single day. Tracking where each claim is in the process helps ensure that services are correctly paid for. But things can go wrong in a number of different ways, there are several types of claims denials. For example, there is the clearing house denial that comes in within 24 hours of filing the claim when missing claim fields are detected or formatting is off. These types of rejections can often be avoided with a good billing software and EMR that scrubs claims before submission. The key performance indicator (KPI) to monitor here is First Pass Resolution Rate (FPRR), which is a percentage of claims that go through clean (sometimes referred to as the Clean Claim Rate). You may want to aim for 95% or higher at this stage.
On the other hand, payer denials may arise from more complex reasons: based on what services the plan allows, exceeding the allowable or contracted limits, or when deductions kick in. A detailed claims denial report can shed light on what is going on in the claims pipeline and help identify patterns of denials For example, if most of your denials are indicating missing authorizations or pre-certifications, you may need to revisit your benefits verification process. The KPI used for this is the Claim Denial Rate, the benchmark for which is 5% or lower.
Physical Therapy Coding Complexities
Coding errors can lead to missed payments or even trigger payer audits. For example, the 97110 code applies to therapeutic exercise. But there are significant differences between a specialized form of therapy and a more generic therapeutic exercise that 97110 points to. Another code like 97530 applies to therapeutic activity, which has a higher reimbursement rate. An EMR coding analysis report can show how therapists are distributing codes across clinical interventions and where the practice could potentially be missing out.
Physical Therapy Billing, All About Time
It might seem like all time should be billed alike in terms of therapies rendered, but that is often not the case. Depending on how the patient is being billed, all time may be lumped together in one lot, or it may need to be separated out and itemized. Medicare requires providers to add all time-based services together (commonly referred to as the Medicare 8-Minute Rule). Other providers require each time-based code to be reported separately (commonly referred to as the commercial or American Medical Association (AMA) 8-Minute Rule). The EMR should automatically calculate the appropriate number of time units based on the patient?s payer rules when processing the claim.
Physical Therapy Billing, Automation The Way Out
The answer clearly lies in establishing robust billing processes that are implemented using integrated practice management software. The following are some of the key, high level workflows that your physical therapy billing software should address:
Configuring the billing rules engine including contract types, fee classes, fee schedules, and master rules for each payer.
Reviewing charges and identifying any problems like missing diagnosis pointers, eval codes, or status of documentation.
Grouping claims by therapist, account type, patient etc. and creating claims batches.
Running the rules engine once again, catching any additional charge or claim issues, and validating claims.
Transmitting finalized claims batches to the clearing house.
Following up with payers per a predefined schedule for collections.
Importing electronic EOBs from the clearing house, auto posting payments, and creating patient statements.
Generating reports including billing & collections, therapist productivity, facility summaries, and audit reports.
When your physical therapy billing needs a tune-up, look to automation to find a way out.
Physical therapy billing practices are considerably fragmented in the US with the large number of payers, Medicare, TRICARE, and private payers. Staying on top of billing rules is an uphill task for any therapist. As a result, it is relatively easy to get shortchanged in terms of billing practices.
On one hand, payers are tightening their procedures leading to declining reimbursements and pressure on physical therapy profitability. On the other, several enforcement actions have been reported around practices like simultaneous multi-patient services billed as single patient, upcoding services, and so on.
The need is to accurately document, submit, and track claims, especially when billing payers such as Medicare, Medicaid, or TRICARE. Recommended best practices include: