reading about cpt code challenges

CPT Coding Challenges for PTs [and How to Overcome Them]

28 June 2023

June 28, 2023

In: Therapy Billing

reading about cpt code challenges


  • Challenges with CPT coding and billing often stem from inadequate training on coding set updates and subpar documentation. 
  • Many physical therapists find it tricky to grasp when to use modifiers and timed codes in patient billing. 
  • Thorough documentation guides for PTs and maintaining up-to-date knowledge of coding sets with the American Physical Therapy Association (APTA) can prevent coding and billing problems.

Complex and evolving coding guidelines can cause CPT coding challenges for physical therapists. Coding and billing challenges can cause PTs to experience delayed reimbursement, disruptions in cash flow, and obstacles to practice growth. What’s more, accidental code violations can result in significant financial penalties. 

To ensure proper coding, billing, and reimbursement for your practice, it’s crucial to be aware of potential problem areas and to stay up to date with coding changes, invest in continuous education and training, and use efficient practice management software.

Common CPT Coding Challenges for PTs

Inaccuracies in CPT codes can lead to claim denials, underpayments, and delays in reimbursement for your practice. While human error accounts for some coding and billing mistakes, several additional CPT coding challenges can impact the claims submission process. 

Failure to Use Current CPT Code Sets

The American Medical Association (AMA) updates the CPT coding system every year. Early updates of Category III CPT codes are released in July before their official implementation date the following January. The AMA also issues a list of errata and technical corrections to address any mistakes and omissions during the review process of CPT codes. 

Staying current on all changes can prevent you from submitting claims with outdated codes, ensuring you receive full reimbursement for your services and minimizing payment delays.

Overlooking Medical Necessity

A significant challenge for physical therapists in CPT coding and billing is demonstrating the medical necessity of their services. Each CPT code relates to a specific level of care, representing the complexity and extent of medical care provided. These codes require accurate and thorough documentation of each aspect of patient care, from initial evaluation through to treatments and follow-ups. 

Each therapy session’s medical necessity must be documented accurately, aligning it with the specific conditions or complaints recognized by insurance carriers. The challenge is further complicated by varying definitions and requirements for proving medical necessity across different insurance providers. 

Accurate documentation can be time-consuming, but it’s pivotal to preventing undercoding. Undercoding occurs when a 30-minute therapy session is reported as 15 minutes, usually due to inadequate justification of the medical necessity for the extra time spent. 

Thus, precise and comprehensive documentation that demonstrates medical necessity is integral to optimal billing, ensuring compliance, preventing claim denials, and safeguarding against potential audits. It’s a complex yet crucial component of physical therapy practice management.

Bundling and Unbundling

Bundling refers to using a single CPT code for several procedures performed within one appointment. Unbundling involves using multiple codes for different parts of the same procedure to maximize reimbursement.

This approach could result in multiple incorrect Medicaid and Medicare payments. If a physical therapy consistently unbundles codes, they are susceptible to federal legal and financial penalties, which could include hefty fines, payment recoupment, loss of provider privileges, and even criminal charges for fraudulent billing practices.

Misinterpreting Modifiers

Modifiers in CPT coding are used as supplements to provide additional information about a procedure and prevent unintentional unbundling. However, incorrect use of modifiers can lead to claim denials and incorrect payments.

For example, if you provide two timed services at different times, you may use modifier -59. This modifier is allowed by CMS when different therapies are provided, such as 10 minutes of manual therapy, 15 minutes of physical performance testing, and 5 minutes of manual therapy. It’s important to note that if two procedures are performed within the same time block, modifier -59 should not be applied to the CPT code for performance testing.

Misidentifying Billable Services

Certain activities that take time are not billable, such as creating progress notes for re-evaluations. CMS does not consider routine continuous assessments of a patient’s progress as a re-evaluation because they aren’t medically necessary. Re-evaluations are billable only when the patient’s condition improves or declines while receiving physical therapy services.

Challenges of Time-Based Billing

Physical therapists may struggle with accurately reporting time-based codes, which require tracking the total duration of specific activities or interventions during a therapy session. With timed codes, your reimbursement is based on how much time you spend providing therapy to a patient. 

Accurately tracking and documenting the time spent on specific activities can be a challenge. PTs must record start and end times for precise reporting, but this can be difficult in a busy clinical setting. PTs must also consider interruptions during therapy sessions, which may require alternative codes.

Meeting specific time thresholds for code selection is also crucial; failure to do so can result in claim denials. To receive Medicare reimbursement for time-based codes, you must provide direct treatment for at least eight minutes. You can’t bill for treatment times less than eight minutes. 

Managing Inconsistent Payer Rules

Insurance plans might offer full or partial coverage for physical therapy. Some plans set a copayment for each visit, while others require patients to pay for part or all of their visits until they reach their deductibles.

These conflicting payer rules can lead to coding challenges for providers. Guideline inconsistencies can create confusion and increase the risk of claim denials. You and your billing staff must review each payer’s guidelines regularly to keep track of payer rule changes to avoid costly billing errors and reimbursement delays.

Understanding ICD-10 Coding

CPT codes apply to the services provided by PTs, while ICD-10 codes describe the patients’ diagnoses. These codes help insurance companies understand why the care you give a patient is medically necessary. CPT codes and ICD codes work together to provide payers with a clear understanding of the patient’s medical progress.

ICD-10 coding guidelines require specific documentation to prove a patient’s diagnosis. In the ICD-10 codes for paraplegia, for example, you will find words such as “unspecified,” “complete,” and “incomplete.” If you have a patient with paraplegia, you need to submit documentation to support the ICD-10 code to avoid a payer denying your claim. 

Navigating Audits

Audits are a significant billing and coding concern for PTs. Insurance companies conduct these evaluations to determine if the care given was essential and complied with appropriate protocols. 

PTs must be prepared for audits by maintaining detailed, thorough documentation of all patient sessions. Keeping comprehensive records using practice management software ensures you can successfully navigate a third-party audit and demonstrate the appropriateness of provided treatments and services. 

Proper documentation also helps to protect reimbursement and maintain compliance with insurance regulations, reducing the likelihood of an audit at your practice. 

physical therapy session

How to Overcome CPT Coding Challenges

To overcome billing challenges, you need to stay updated with the latest coding sets and guidelines, and maintain accurate patient care documentation. Continuous education and training are key.

Medical billing and coding have experienced significant changes due to the Affordable Care Act (ACA). The ACA introduced codes for preventive services and implemented Medicare fee schedules. Coders must now know about regulations regarding coverage, cost-sharing, and access.

They must also be aware of annual changes to coding systems. The AMA’s code updates become effective on January 1st of each year. New, revised, and deleted codes are added to the code set every year. As of 2023, there are 10,969 codes, and the set continues to grow and change with advances in medical science and health technology. 

With the continuous updates to CPT codes, keeping up with the changes is a must to ensure accurate billing and avoid coding errors. 

These strategies can help prevent your practice from dealing with denied claims and delays: 

  • Leverage American Physical Therapy Association (APTA) resources: You can subscribe to the APTA’s email lists and stay up to date with practice management and coding updates on their website. You can use this member benefit to improve your coding practices and submit accurate and compliant claims. The APTA works with CMS to review and delete edits impacting common physical therapy code pairs, making the APTA’s resources even more helpful.
  • Update your coding manuals: Investing in annually updated coding manuals can save your practice money in the long term. In addition to the new changes made each year, coding manuals contain detailed searchable guidelines and cross-references to help you understand the proper use of each code.
  • Stay up to date on payer rules: Attend payer meetings, review payer websites, and reach out to payer representatives when necessary. You can sign up for email newsletters from your carriers and payers to keep your coding practices current. Serving on payer committees and using care management resources periodically can help you develop a rapport with critical payer staff members and provide valuable insights into the payers’ expectations.
  • Attend MAC conferences: Teleconferences and webinars hosted by your Medicare Administrative Contractor (MAC) can help your coders stay up to date on Medicare policies and regulations. These events cover a range of relevant topics, such as the use of modifiers and enrollment rules, and may offer materials from previous conferences.
  • Establish standard procedures for documentation: A comprehensive documentation guide for physical therapists is essential to reducing the risk of undercoding by establishing standard procedures for coding. Standards will help you capture all the necessary information and document thoroughly, reducing the chances of inaccuracies, undercoding, and lost revenue.
  • Use technology: Practice management software like ClinicSource can simplify the coding process, reduce errors, and improve coding accuracy. ClinicSource contains documentation templates, automated updates to the CPT codes, and streamlined billing workflows, making it easier to stay updated with the latest coding changes.
  • Understand your claims data: Regularly review your practice and insurer data, including quality metrics and patient records. Modern therapy practice management software like ClinicSource offers reporting features that provide valuable insight into working with different payers and collecting payments owed. 

viewing coding on a tablet

Simplify CPT Coding and Billing Challenges with ClinicSource

ClinicSource is 100% accurate online therapy billing software that simplifies coding and billing and helps you maximize claims. It is completely integrated with the other ClinicSource components, saving you countless hours on claims and invoicing. 

With ClinicSource, you can easily:

  • Create and submit accurate claims: ClinicSource’s built-in coding engine helps you select the correct CPT codes and diagnoses for your services. It also automatically generates claims forms, so you don’t have to worry about re-keying data.
  • Track insurance payments: ClinicSource tracks all insurance payments, so you can easily see when and how much you’ve been paid. It also sends you reminders when payments are due, so you can avoid late fees.
  • Manage patient accounts: ClinicSource helps you manage patient accounts, including collecting payments, scheduling appointments, and sending reminders. It also provides you with reports on patient demographics, insurance coverage, and treatment history.

ClinicSource is HIPAA compliant and easy to use, streamlining practice workflows from scheduling to collections. 

To learn more about how ClinicSource can help you simplify coding and billing, book a demo today to see it in action!


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