Physical Therapy Billing
Learn the Basics

Learn the basics and special needs of physical therapy billing in this guide. Physical therapy billing is different, and potentially more profitable, than regular physician billing...

Physical therapy is a special type of therapeutic service, where a certified physical therapist provides services to a patient.

Often these patients are recovering from an injury or illness. As such they're not acutely ill or injured - they're just suffering the after-effects of a previous condition.

Because of this, there are many different aspects of physical therapy billing that you don't usually find in regular medical billing from a physician's office.

Physical therapy is often associated with the two other types of medical therapy services: occupational and speech therapy.

Each of these therapy services has special requirements and billing guidelines, to make sure the services are paid by the patient's insurance company.

Looking for a deeper guide to physical therapy billing?

We recommend the ebook Introduction to Physical Therapy, Occupational Therapy & Speech Therapy Billing, published by the mother/daughter medical billing team at Learn more about the book here.

To receive any payment for any type of therapy, there are two main requirements:

  • The service must not be an excluded service, meaning that it's covered by the patient's insurance policy, and
  • The service must meet the conditions to be considered reasonable and necessary

Most of what a physical therapy billing professional does focuses on making sure that the services performed are considered reasonable and necessary.

Reasonable and Necessary

Physical therapy

To meet this requirement, physical therapy services must meet two criteria:

  • The service provided must be considered to be a reasonable treatment for the patient's condition.

    For example, physical therapy provided on a patient's arm wouldn't be considered reasonable and necessary for a patient with a broken leg. The treatment provided must treat the specific nature of the patient's illness or injury.

  • The service provided has to be of such an extent that it must be provided by a qualified physical or occupational therapist.

    In other words, services provided by a physical therapist won't be covered if the service is something that an uncertified professional can do.

    For example, a lightly sprained ankle, which can be wrapped and monitored by a physician or orthopedist, isn't eligible for services provided by a physical therapist.

If neither of these conditions are met by the patient and his or her condition, they won't be reimbursed by the patient's insurance.

This doesn't mean, however, that you can't perform physical therapy services on patients who don't meet these conditions. You can still provide services, but they'll have to be provided on a self-pay basis.

If this is the case, make sure your office has a policy for non-covered services and how they'll be billed to patients. You may also want to develop a sliding scale of payments or a discount amount for patients who don't have insurance coverage for certain services.

Diagnosis Codes: Special Requirements

Physical therapy requires the correct codes to bill

You can't bill physical, occupational, or speech-therapy services without the correct diagnosis codes.

Out of the entire ICD-9 codes manual, there are only a handful of diagnosis codes that are eligible for reimbursement under physical therapy billing guidelines.

More specifically, the diagnosis codes that you use must describe a specific, underlying condition or body part affected, which resulted in the current need for therapy services.

In plainer words, the diagnosis code has to specify the patient's condition, which is a direct result of an underlying condition, illness, or injury.

Here's a list of some accepted ICD-9 codes which are covered for physical therapy services:

  • V43.61-V43.69: Joint replacement status
  • V49.71-V49.77: Lower limb amputation status
  • 330.0-337.9: Hereditary and degenerative diseases of the central nervous system
  • 430-438.9: Cerebrovascular disease
  • 715.09: Osteoarthritis, and allied disorders, multiple sites
  • 781.2: Abnormality of gait
  • 820.00-820.9: Fracture of neck of femur
  • 953.0-953.8: Injury to nerve roots and spinal plexus

These diagnosis codes describe particular conditions, which may directly indicate a need for physical therapy services.

You can use additional codes, however, to indicate the complexity of an underlying condition which necessitates physical therapy. Some of these diagnosis codes include:

  • V45.81-V45.82, V45.89: Other post-procedural status
  • 278.00-278.01: Obesity and morbid obesity
  • 310.0-310.9: Other non-psychotic mental disorders due to brain damage
  • 317: Mild mental retardation
  • 415.0-417.9: Diseases of pulmonary circulation
  • 707.00-707.9: Chronic ulcer of skin
  • 780.31-780.39: Convulsions
  • 880.00-884.2: Open wound of upper limb
  • 941.00-949.5: Burns

All of these diagnosis codes can be used for physical therapy services. Just as long as you bill them along with an accompanying ICD-9 code, as part of a complexity of the other ICD-9 code.

The tip of the iceberg: additional requirements

There are lots more requirements and regulations for billing physical, occupational, and speech therapy.

These include strict definitions of each type of therapist (including student therapists), and what types of services they're allowed to perform.

There are also strict rules for establishing plans of care. These are directly related to the therapy services provided, and written into a detailed treatment plan. They must be certified for a specific amount of time, and have to be renewed if the patient still needs services once the certification expires.

Additionally, requirements change depending on the type of facility in which you are providing the services.

Unless certain conditions exist, therapy services are only covered if they're provided in the therapist's office or the patient's home. Other places of service include schools, homeless shelters, group homes, and custodial care facilities.

If the services are provided in a hospital or inpatient facility, they must be billed under different regulations, according to Medicare Type A requirements.

What's in it for you?

Physical therapy

You may be wondering: "with all these requirements, why would anyone want to work in physical therapy billing?"

Probably the simplest reason is earning potential. Because a physical therapy biller possesses a very desirable and knowledgeable skill set, they can demand a much higher rate of pay than regular physician billing specialists.

Furthermore, you may find the treatments interesting, as well as the therapeutic environment of the physical therapist's office.

No matter which specialty you decide on in billing and coding, try to find the office setting that works best with your personality, professional skills, and salary requirements. Perhaps physical therapy billing will be the right choice for you!

The ebook Introduction to Physical Therapy, Occupational Therapy & Speech Therapy Billing has much more in-depth information on this topic.

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