Physical Therapy Caps Q/A

February 1st, 2019 - Wyn Staheli, Director of Research
Categories:   CPT® Coding   HCPCS Coding   Modifiers   Chiropractic   Physical Medicine|Physical Therapy  
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Question: How do I code it so that PT services in a chiropractic office don’t count against their PT visit max? Is there a way to code claims so that they are considered chiropractic only? But still get compensated enough? We have been running into some issues as of late pertaining to how we code our claims; the chiropractor here also has physical therapy privileges which I believe is where we are running into the problem. She has been coding her claims so that services are considered under both chiro and PT, which in turn exhausts her patient’s benefits faster (e.g., A patient has 20 chiro visits and 30 pts visit allowed; the way the claims are coded the first 20 ‘chiro visits’ would also be considered PT, thus giving the patient only 30 visits in total versus 20 chiro visits and then 30 additional PT visits).

Answer: This is unfortunately a known problem that has existed for years. Physical therapy practices are often hard hit by this situation. If a physical therapy service is provided ANYWHERE, it then counts toward a PT visit — period. There is no way around this because payment systems are set up based on the codes submitted for claims — not who provides the service. In fact, the Medicare therapy cap includes both physical therapy (PT) and speech-language pathology (SLP) services, so if the patient is getting SLP services, that also counts towards the cap.

It should be noted that as of 2018, Medicare removed the cap on physical therapy services so providers can use modifier KX with the PT service and still be paid, as long as the service is still considered reasonable and necessary. Since payers often follow Medicare, be sure to check with other payers to determine their individual policies. They might allow additional services if it can be demonstrated that the patient is still progressing and will benefit from further treatment.

You might try and appeal with the payer. For example, if treatment is required for separate conditions, the patient may qualify for either a new condition or a separate condition that has previously received physical therapy for another indication. This may qualify the patient to be eligible to receive coverage for an additional course of physical therapy. Although, it should be noted that an exacerbation or flare-up of a chronic illness is not considered a new incident of illness. Additional coverage beyond the original visit limitation must typically be requested with the payer.

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