Are you Billing your Best?

Thomas,Mia ret pp 5 x 7 By Mia Thomas PT, DPT



Billing is a mysterious creature that many therapists must learn on the job, and typically they learn from untrained peers or through clinical instructors. Learning from individuals that do not specialize in medical billing or coding can pass down bad habits and may prevent therapists from learning about the most recent changes in billing policies.


Medicare made many changes in 2016, with switching from ICD-9 codes to ICD-10, to beginning PQRS reporting, G codes, and introducing X (U,S, or E) modifiers. Adopting all of these new practices required by Medicare can increase reimbursement rates and decrease over-billing.


Many therapists have become familiar with the new ICD-10 coding system; but they may not be aware that some codes are more likely to get reimbursed than others. For example, a therapist that bills for M25.511 Pain in Right Shoulder and for M25.512 Pain in Left Shoulder is more likely to get reimbursed than a therapist that bills M25.519 Pain in Shoulder, Unspecified. Furthermore, any codes that end in “9” or with “unspecified” are less likely to get reimbursed than more specific codes, even if that mean adding multiple codes to completely describe the condition.


Another practice that many therapists are aware of (though they may wish they weren’t) is PQRS reporting. This requires therapists to report a variety of different measures for patient’s using Medicare, including: Body Mass Index, pain scales, falls risk and plan of care, medications, and two outcome measures related to their condition. Practices that do not participate in PQRS reporting will receive a 2% penalty in 2017.


One new billing practice that many therapists are not familiar with is using modifiers to ensure the best reimbursements. Did you know that modifiers are required when you bill for an evaluation and treatment measures in the same day in order to get reimbursed for both? Don’t worry you were not the only one. Modifiers may also be required when you bill for two treatment techniques that require a modifier; one common couplet is 97102 Mechanical Traction and 97140 Manual Therapy.


There are only more changes to come for 2017, so make sure you become proficient in 2016’s changes so next year’s don’t overwhelm you!