With the continued changes being made to billing guidelines for physical therapy, misunderstandings and confusion can lead to increased billing errors and decreased reimbursement. In addition to traditional CPT codes there are also additional physical therapy modifiers that exist, and are used in certain situations to ensure reimbursement. 

Due to the level of specificity needed for maximum reimbursement, it’s important that physical therapists understand what PT modifiers are and how they are used in the billing process in order to receive maximum reimbursement for their services. If you’re unsure of how to bill clients through their insurance, Healthie can help you build Superbills.

The top physical therapy modifiers PT’s should know

There are a variety of modifier codes that PTs can include on their insurance claim. Below we have listed the top physical therapy outpatient modifiers we think all PT should know in order to reduce documentation errors and increase reimbursement. 

GP Modifier is used for all “services provided under an outpatient physical therapy plan of care.” It is important that this physical therapy outpatient modifier code is utilized to ensure reimbursement. 

CQ Modifier is used for all “outpatient physical therapy services furnished in whole or in part by a physical therapy assistant.”

KX Modifier can be used when a patient has reached their physical therapy maximum for the year. As of 2021, the Medicare cap has increased to $2,110 for PT services. Once the cap has been reached the KX modifier is used. On any claims with PT Modifier KX, the PT must document medical necessity for the continuation of care. Medicare can then request a review for any visits after the cap; the payment will be denied if medical necessity cannot be proven. 

Modifier 59  As defined by CMS: “Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day.” Providers can use Modifier 59 to identify any procedures or services that are not usually performed together, but were appropriate under the given circumstances. PT Modifier 59 is to be only used when there is no other appropriate modifier available, as a “last resort.”

However, the National Correct Coding Initiative has identified certain services that PTs commonly perform together; these are known as “edit pairs.” If you bill CPT codes that are part of one of these pairs, you’ll receive payment for just one of those codes. You must determine if you’re providing linked services or wholly separate services before using Modifier 59. 

Modifier XE, XP, XS, and XU are modifier codes that can be used to bypass an edit pair, by claiming a distinct encounter, anatomical structure, or practitioner, or simply an unusual service. 

For questions or concerns about PT modifiers and if they are required/applicable with private insurances, it is important that physical therapists contact third-party payers directly. 

You and your staff provide high quality rehabilitative care and deserve to be reimbursed for it. Taking the time to understand what physical therapy outpatient modifiers are and how they should be incorporated into the billing process, will lead you and your staff to decreasing billing errors made and increasing your clinics overall reimbursement. 

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Physical therapy modifiers and EHRs

When creating insurance claims with PT modifiers, it’s important to have client chart notes easily accessible so that you can bill the proper diagnostic and procedural codes; selecting an EHR that integrates with a billing tool is key to streamlining your billing and insurance workflows within your physical therapy practice. This integration can reduce any errors leading to claims denials, speed up your overall insurance billing process, and ensure that you get properly reimbursed for the services you provide. 

Healthie’s insurance billing features allow you to easily generate CMS-1500s within the platform, submit claims, and track claim status and reimbursement. With Healthie’s integrated EHR and billing features, you can:

• Easily add PT modifiers to CMS-1500 forms
• Save CPT and ICD-10 codes as favorites to streamline the claim generation process
• Pre-fill information from charting notes and client information directly into insurance claims
• Integrate with Office Ally for simple claims submission and tracking
• Use Anatomical Charting to accurately track patient progress