Skip to main content

5 Physical Therapy Billing Tips to Increase Revenue

Yesterday, we highlighted the $10.7 billion software problem in physical therapy, primarily caused by bad software, leading to indefensible documentation and bad billing processes. Today, we give you five tips to improve your physical therapy billing. We’ll focus on tips that will help drive higher revenue according to medical billers that we interviewed.

Billing Tip #1 – GP and KX modifiers for Medicare

Medicare is a pain for physical therapists to deal with. Here are two starting tips to deal with Medicare billing for physical therapy.

GP modifier

Every line item on every claim that you submit should include the GP modifier. The GP modifier states that the “services [were] delivers under an outpatient physical therapy plan of care.” Failure to attach this modifier to a line item will result in that line item not being paid.

KX modifer

The KX modifier is used when a patient has reached their physical therapy cap for the year. In 2019, the allowed amount cap is $2,040. Every claim you submit after that cap requires the KX modifier on each line item. The KX modifier is used to indicate that “your claim has met specific documentation requirements in the [patient’s] policy.”

In addition to applying the KX modifier to each line item, you MUST ensure that your therapists are clearly documenting the need for continued skilled care. After the $2,040 limit, Medicare is able to request a medical review for all visits after the cap and will deny payment if the medical necessity is not clearly documented.

Billing Tip #2 – Track PR-100 codes and collect checks from patients

A common problem for physical therapy clinics is not easily tracking checks being sent to the patients. All too often, we have seen clinics have outstanding patient balances of $1,000+ and no system in place to track patient balances.

“Our existing software does not give us the ability to quickly see which patients are receiving payment checks from carriers,” a billing employee at Edge Physical Therapy & Sports Medicine said. “If the patient is not responsible and bringing checks to us actively, we often fall way behind on collecting payments with no real method to track these balances.”

The key is to look for PR-100 codes on Explanation of Benefit (EOB) documents and ERAs. If you see this remittance code on the response, you know the check is going to the patient. Prompt EMR was built with this in mind and automatically alerts you that the check was sent to the patient when this code is received.

“Prompt EMR’s ability to track checks to patients is huge for small physical therapy clinics,” said Kelly Langschultz, President of Precision Billing & Consulting. “It makes it easy for a front desk employee to see a patient’s balance and it automatically applies to the balance when the check is sent to the patient.

Billing Tip #3 – Proper Medicare coding

Medicare is very particular about their rules for physical therapy and we are here to help. Here is a look at some codes that Medicare doesn’t pay for or only pays in a limited amount.

Non-payable Medicare codes

CPT code 97014 (electric stimulation therapy – unattended): Medicare, and many other insurance carriers, do not pay for Code 97014, unattended electric stimulation therapy. On the other hand, Medicare and most other insurance carriers do pay for attended e-stim, CPT code 97032. If you performed the e-stim with the patient, we recommend you bill 97032 and clearly document the procedure in your notes.

CPT code 97010 (hot/cold packs): Medicare considers 97010 a bundled service and does not pay for the code. We recommend you don’t bill this code as you will not be paid for it.

One-unit max

The following codes Medicare will generally only reimburse for up to one unit per visit. When billing any of these codes, you must clearly document their medical necessity. Additionally, if you are attempting to bill greater than one unit of any of these codes, you must clearly document why, although in general, that will not get you paid for more than one unit.

  • CPT code 97012 (mechanical traction)
  • CPT code 97018 (paraffin Bath)
  • CPT code 97028 (pltraviolet)

Billing Tip #4 – CO-50 – Medical necessity denial

One of the most common denial codes in physical therapy billing is a CO-50 denial for medical necessity.

“The CO-50 medical necessity denial is 60-70% of the denials I see in physical therapy,” Langschultz said. “As long as you have quality documentation and understand that the process is to simply appeal with your notes, you have a very high chance of getting paid for these visits. Unfortunately, too many clinics fail to appeal these claims or fail to document well, and leave thousands of dollars of revenue on the table.”

If you get a medical necessity denial, the process should always be appeal with notes.

Billing Tip #5 – Oxford vs. United

A common billing mistake that causes claim rejections is selecting the wrong carrier when dealing with Oxford and United Healthcare, due to the similarities between cards. How do you solve this problem?

“The solution is easy. With an Oxford plan, the first digit in the member ID is 1,” a biller said. “With a United Healthcare plan, the first digit in the member ID is 9.”

This is an easy fix to avoid rejections and reduce the time to get paid for each claim.

Prompt EMR & practice management – A fully-integrated physical therapy software platform

Prompt EMR was designed and developed with these billing tips, along with many others, in mind. Audrey Killip, the billing manager at Edge Physical Therapy and Sports Medicine, discusses how Prompt EMR has helped improve their billing practices.

“Prompt EMR and practice management was built to make billing easy,” she said. “With the built-in billing logic as well as an all-in-one master screen where I can review notes, edit and submit claims, track responses, and post payments, Prompt has truly made the process simple. You no longer need to click back and forth and use multiple systems, everything you need is right there on one screen, and they prevent you from doing things you shouldn’t be doing.”

See how Prompt EMR and practice management software will help you implement these tips! Schedule a demo today!

Prompt Staff

Prompt Therapy Solutions builds practice management software for physical therapy clinics ranging from single provider practices and startups, to large enterprise organizations.

This will close in 0 seconds

This will close in 0 seconds