CPT Codes for Physical Therapy Evaluation: A Better Understanding of Billing and Coding Guidelines

For the past few years, the healthcare industry has been under continuous evaluation. Not just the regulations amended for insurance providers and healthcare providers but patients as well. People visit doctors for their tailored needs, however, visiting a physical therapist needs serious bodily pain, injury, or sprain.

To reimburse the treatment, practitioners need to use the CPT codes. CPT codes for physical therapy evaluation can differ from those normally used across medical or healthcare reimbursements. Why? Because not many services can be provided via therapists and visiting home.

Physical therapy is one of those few services that restore the health of the patient through physical activities and stimulating muscles by muscular motions. To report physical therapy evaluation CPT codes CPT 97161, CPT 97162, CPT 97163, CPT 97164, and CPT 97140 can be used.

For home health physical therapy evaluation, report CPT G0151, CPT G0157 & CPT G0158 codes for correct and accurate evaluation.

When modality therapy is practiced, CPT 97014 would be reported, other CPT codes include CPR 97535 for compensatory training and self-care management training, CPT 97530 for therapeutic activities to improve physical movements, and CPT 97112 reported for neuromuscular reeducation.

Physical therapists also provide therapies for pelvic floor dysfunction. For these treatments, CPT 90913 and CPT 90912 are reported.

Physical Therapy CPT codes coding guidelines

A physical therapist uses physical therapy codes for the services provided to restore and maintain the health of patients using physical techniques and activities. To reimburse for the provided services, the American Medical Association has regularized proper guidelines for reporting CPT codes for physical therapy billing claims.

Before a therapist or physician performs medication or therapeutic therapy, they need to provide a physical therapy evaluation. For billing those physical therapy evaluation services, they can bill for E&M services but several CPT codes are specifically designed for physical therapists.

Physical Therapy CPT codes coding guidelines
source:familymedicineaustin.com

CPT codes for physical therapy evaluation

Physical therapy evaluation contains a dynamic process in which the clinical data gathered during treatment helps physical therapists to make decisions.

Examination during evaluation involves compiling a comprehensive history, directing labs and tests, and previewing healthcare systems. Once the evaluation is made, the physician or physical therapist analyzes the findings, if the reason for evaluation is determined properly, they establish a comprehensive diagnosis for physical therapy, and provide the prognosis to develop a complete plan for treatments and therapy to attain future goals and forecast expected and unexpected results, make anticipation for both scenarios and make decisions to conclude complete care.

Since it’s a long-term process and needs a proper follow-up regarding evaluation and treatment for physical therapies, providers are strict on AMA coding guidelines. These coding guidelines are further discussed in the article underneath.

Coding guidelines

Once the whole process of evaluation is done and the decisions are made for a particular treatment of a subject, the story doesn’t end here. According to Medicare guidelines, a re-evaluation is needed to be done after every nine visits of a patient. An 8-minute rule is applied to the reported codes on the reimbursement claims where the number of time codes units depends on the duration a physical therapist spends on a patient during one encounter.

Besides, there are three different types of physical therapy evaluation i.e., low, moderate, and high complexity. These evaluation levels are performed after analyzing how complex the condition of the patient is at the given moment. For these levels of physical therapy evaluations, these CPT codes are reported;

  • CPT 97161
  • CPT 97162
  • CPT 97163
  • CPT 97164

Description for CPT code 97161;

The code CPT 97161 is a physical therapy evaluation code that can be reported for low complexities at a therapeutic level.

Complexity ratio – Low

Time – 20 minutes

Physical therapy procedure – Face-to-face evaluation with the family of the patient (because of low complexity) in best practice, with the patient.

This evaluation service is not limited to one place. It can be provided at any place, for example at a patient’s home, outpatient hospital facility, and physical therapist’s office. It is important to note the place where the services are performed when taking notes for HER. The place will be mentioned in the claim form when submitting reimbursement claims.

In addition, the rate for the services provided in the office or outpatient medical facility is the same.

Description for CPT code 97162

The code CPT 97162 is a physical therapy evaluation code that can be reported for moderate complexities at a therapeutic level.

Complexity ratio – Low

Time – 30 minutes

Physical therapy procedure – Face-to-face evaluation with the family of the patient (because of moderate complexity) in best practice, with the patient.

Description for CPT code 97163

The code CPT 97163 is a physical therapy evaluation code that can be reported for high complexities at a therapeutic level

Complexity ratio – High

Time – 45 minutes

Physical therapy procedure – Face-to-face evaluation.

Description for CPT code 97164

The code CPT 97164 is a physical therapy re-evaluation code that can be reported for establishing re-evaluating treatment and care.

Time – 20 minutes

Physical therapy procedure- Face to face

97140 CPT code for physical therapy

The code CPT 97140 is a physical therapy code that can be reported for physical therapy techniques. These techniques must be used for more than one region.

Time – 15 minutes

CPT code 97140 is used to report;

  • Mobilization
  • Manual lymphatic drainage
  • Manual – traction
  • Manipulation

Previously issued physical therapy CPT codes

CPT codes for home health physical therapy service
source:fullrangeptnv.com

United States Centers of Medical Sciences have issued a range of CPT codes and there are continuous amendments in codes reported for every practice and provided service.

Many CPT codes are still in use with the codes released earlier in 2020. They include;

CPT codes for home health physical therapy service

When a therapist visits places to perform therapy services, three CPT codes can be used to report for home health physical therapy. CPT G0157 is designed for assistant therapists, CPT G0159 is for establishing the therapy program which is determined to perform in a hospice setting or home, and CPT G0151 is for physical therapists.

Description for CPT code 97014

The code CPT 97014 is a physical therapy code that can be reported for the application of modality and electric stimulation in one or more areas.

Description;

For reporting CPT code 97014, the physical therapy provider must stimulate the muscle function by electrical stimulation method for more than one area. With stimulation, pain/edema would be alleviated but healing would be enhanced.

It depends on the condition and the clinician’s diagnosis to select the type of electrical stimulation. The stimulation treatment requires continuous supervision; this is why physicians are allowed to report one stimulation process in a day. However, treatments other than physical stimulation can be provided and reported on the same day.

Usage of Modifier;

In addition to providing more services than stimulation on the same date or day of services, a modifier 76 would be used with the CPT 97140 code. The service code for the additional services can be reported separately which defines the number of services performed on the same date apart from electrical stimulation.

On reporting self-care management and compensatory training CPT 97535 must be used.

Description for CPT code 97112

The code CPT 97112 is a physical therapy code that can be reported for Neuromuscular Re-education (Therapeutic procedure).

Description for CPT code 97530

The code CPT 97530 is a physical therapy code that can be used for performing therapeutic activities to improve physical functions by implementing dynamic activities.

Physical therapy services for workers

When an injury is reported at a workplace, the cost of services can be daunting. The patient would like to bill the worker company instead of going for a primary health insurance provider. As a worker, if you need to take the services of a physical therapist after an injury, you likely need to have pre-authorization from your company and inform them of the type of services a physical therapist will perform.

The process and the CPT codes for the physical therapist for WC will be the same, however, the amount for the therapist services paid can vary according to WC and the level of therapeutic services.

Physical therapy and CPT codes used for pelvic floor dysfunction

CPT codes can be reported for physical therapy and pelvic floor dysfunction reported include CPT 90913 and CPT 90912. These physical therapy services are performed to maintain and restore pelvic floor function.

When documenting the physical therapy procedures performed on the pelvic floor, specify the service precisely as they are performed such as ‘pelvic muscles exercise/therapy. Plus, these pelvic floor dysfunction therapies should be mainly for urinary incontinence.

Description for CPT code 97116

The code CPT 97116 is a physical therapy code that can be reported for Gait training. Gait training is designed to involve exercises with the therapy where they help the patient to stand and walk while moving gradually after an injury or accident. This intention helps in improve muscle function and helps improves balance in twisted joints, and rebuilds posture, and endurance.

The practice further helps in improving muscle memory by using repetitive moments and motions. The main goal of gait training is to bring back someone on his legs to restore the chances of mobility and decrease the chance of slips and falls while walking.

Some common reasons why people might need gait training include;

  • Broken pelvis
  • Broken legs
  • Stroke
  • Joint replacement
  • Spinal cord injuries
  • Neurological disorders
  • Brain injuries
  • Musculoskeletal disorders

Description for CPT code 97150

The code CPT 97150 is a physical therapy code that can be reported for group therapy. Group therapy is designed to provide services to two or more patients at a time. The therapy is given to multiple patients in a place where not all the patients need to perform the same exercise.

These activities can be performed at a pool, at a gym, or in a refreshing environment. As this therapy is based on group settings, then a therapist assistant is required to monitor the patients thoroughly.

Description for CPT code 97530

The code CPT 97530 is a physical therapy code that can be reported for therapeutic activities that require face-to-face interaction with the therapist. This dynamic therapy involves a range of exercises to enhance the functions of ligaments, muscles, and other tissues in the body. The range of dynamic activities includes;

  • Moving to a stand position from lying or sitting
  • Bed mobility
  • Hip-hinge training
  • Throwing a ball
  • Squatting
  • Lifting heavy objects
  • Getting in and out of a vehicle
  • Going up and downstairs
  • Getting in and out of bed safely

Description for CPT code 97750

The code CPT 97750 is a physical therapy code that is reported for the physical measurement and performance test. Before performing the performance test and making physical measurements, the physical therapist must understand the situation and the needs of the patient.

To identify the condition of a patient, a physical therapist needs to perform multiple tests to determine the physical performance of the body. These tests include;

  • Cybex testing
  • Functional capacity evaluations
  • Functional assessments
  • Pinch tests
  • Sensory tests
  • Grip tests
  • Exertional testing
  • Sport-related tests
  • throwing or running
  • Video analysis of gait

Some less common CPT physical therapy codes include;

  • 97010: Hot or cold packs therapy
  • 97012: Mechanical traction therapy
  • 97014: Electric stimulation therapy
  • 97016: Vasopneumatic device therapy
  • 97018: Paraffin bath therapy
  • 97022: Whirlpool therapy
  • 97024: Diathermy
  • 97026: Infrared therapy
  • 97028: Ultraviolet therapy
  • 97032: Electrical stimulation
  • 97033: Electric current therapy
  • 97034: Contrast bath therapy
  • 97035: Ultrasound therapy
  • 97036: Hydrotherapy
  • 97113: Aquatic therapy/exercises
  • 97124: A massage therapy
  • 97127: Therapeutic interventions with a focus on cognitive function
  • 97139: Physical medicine procedure
  • 97151: Behavioral identification assessment
  • 97153: Adaptive behavior treatment by protocol
  • 97154: Group adaptive behavior treatment by protocol
  • 97155: Adaptive behavior treatment by protocol (modification)
  • 97156: Family adaptive behavior treatment guidance
  • 97157: Multi-family adaptive behavior treatment guidance
  • 97542: Wheelchair Management
  • 97158: Group adaptive behavior treatment
  • 97750: Physical performance test
  • 97755: Assistive technology assessment
  • 97760: Orthotic management and training, the first encounter
  • 97761: Prosthetic training, the first encounter
  • 97762: Orthotic/Prosthetic Checkout
  • 97763: Orthotic/prosthetic management, subsequent encounters.