Therapy Billing Explained – Why Costs and CPT Codes May Vary Between Visits

Navigating the world of physical therapy billing can be complex for patients, providers, and payers alike. Many factors influence the total cost of a PT session, including the type of therapy provided, the Current Procedural Terminology (CPT) codes used, and insurance reimbursement policies. Understanding why different codes are used and how they impact costs can help all stakeholders make informed decisions.

Key Differences in Physical Therapy Procedures and CPT Codes

Physical therapists utilize various treatment modalities to help patients regain mobility, reduce pain, and improve function. Each intervention is billed under a specific CPT code, which reflects the service’s complexity and purpose. Below are some of the most commonly used PT interventions and their corresponding CPT codes.

1. Therapeutic Activities (CPT Code 97530)

Therapeutic activities involve dynamic movements designed to improve functional performance. These activities often include lifting, bending, carrying, or reaching tasks, focusing on real-world applications such as work, self-care, or recreational activities. This intervention is often used towards the middle to later stages of treatment, as the patient’s symptoms have improved and they’re tolerating functional tasks with fewer subjective complaints. In the workers’ compensation realm, therapists understand that it’s important to prioritize Therapeutic Activity as an intervention, as this often reflects job specific tasks and is essential to facilitating return to work.

• Purpose: To improve function, mobility, and coordination
• Example Activities: Standing from a seated position, floor to waist lifts, pushing a weighted sled, or stepping up onto a platform

2. Therapeutic Exercises (CPT Code 97110)

Therapeutic exercises focus on strength, endurance, flexibility, and range of motion. This intervention is more simplistic than therapeutic activities, although they often pair nicely together. For example, a long arc quad (also known as a seated knee extension) is a therapeutic exercise. This activity is performed for the purpose of moving the knee through full knee extension and building strength in the quadricep muscle. This is often a precursor to more functional, therapeutic activities like squatting, walking, etc.

• Purpose: To improve muscle function, flexibility, and joint mobility
• Example Activities: Dumbbell strengthening exercises, stretching, and range-of-motion exercises

3. Manual Therapy (CPT Code 97140)

Manual therapy refers to hands-on techniques that improve tissue mobility and reduce pain. Manual therapy enhances patient care and outcomes in a variety of ways , as discussed in prior blog posts. This intervention is often used early in treatment, when patients are more symptomatic. Implementing manual therapy reduces pain, improved movement, and allows for faster exercise progression.

• Purpose: To mobilize soft tissues and joints, improve circulation, reduce pain, and restore function
• Example Techniques: Myofascial release, joint mobilization, passive range of motion, neural mobilizations, and manual lymphatic drainage

4. Neuromuscular Reeducation (CPT Code 97112)

Neuromuscular reeducation is used to restore balance, coordination, and movement control. While often assumed to be leveraged most often in neurological cases, neuromuscular reeducation can be used in a variety of orthopedic cases, ranging from retraining coordination of scapular stabilizers via PNF patterns to improving proprioceptive awareness following an ankle sprain.

• Purpose: To retrain muscle movement patterns and improve proprioception
• Example Activities: Balance training, postural control exercises, and stability ball exercises

5. Work Conditioning (CPT Code 97545, 97546)

Work conditioning is a structured program designed to help injured workers return to their job duties. Work conditioning typically occurs after formal physical therapy has ended. In short, work conditioning helps to bridge the gap that often develops from time away from work after an injury. Not only does work conditioning address specific job demands (like floor to waist lifts, pushing/pulling, carrying etc.) but it also aims to improve the injured worker’s cardiovascular fitness in preparation for a return to full duty.

• Purpose: To improve strength, endurance, and job-specific functional abilities
• Example Activities: Simulated job tasks, lifting exercises, or cardiovascular endurance training

Why Do Billing Codes and Costs Vary Between Visits?

Several factors contribute to the variation in CPT codes and total costs per session:

1. Patient Needs & Treatment Plan

Each session is tailored to the patient’s progress, condition, and treatment goals. A session may include therapeutic exercises and therapeutic activity one day and a mix of manual therapy and neuromuscular reeducation the next. This variation in treatments will require use of different CPT codes; which will result in different total costs/visit.

2. Time Spent on Each Intervention

Most PT codes are time-based meaning that the total cost of a session depends on the duration and number of interventions performed. For example, some treatment sessions may include 30 minutes of therapeutic exercise (resulting in a certain number of billable units for that CPT code). Another session may only include 10 minutes of therapeutic exercise (resulting in a reduced number of billable units compared to the prior session).

3. Therapist’s Clinical Judgment

The therapist determines which interventions are most appropriate for a given session based on patient’s condition, progress, goals, and prior responses to treatment. Again, progression of a plan of care often results in different interventions, different application of CPT codes, and therefore different billable amounts/visit.

Conclusion

Understanding the differences between CPT codes and when/how they’re applied can help patients and stakeholders understand and navigate therapy billing more effectively. The variation in CPT codes and costs from one visit to another reflects individualized care and treatment progression.
To learn more about how Upstream Rehabilitation and our family of brands can assist with Workers’ Compensation and how physical therapy plays an effective role in helping injured workers return to work, contact our Workers’ Compensation team today!