Common coding mistakes often lead to denied claims and payment reductions in physical therapy practices. Even minor errors in coding can lead to substantial financial losses over time. Understanding and addressing these common errors will help your practice reduce denials and enhance your bottom line.
When you've mastered these general requirements, head over to Navigating Payer Specific Billing Requirements,
our article on the specific requirements that Zaya payers are seeking, along with the best practices outlined below.
Topics Covered
Understanding NCCI Edits
NCCI (National Correct Coding Initiative) edits are a set of guidelines established by the Centers for Medicare & Medicaid Services (CMS) to prevent improper coding and billing practices. This program focuses on codes that may describe overlapping services, such as those involving similar or related anatomical sites, or related services.
Clinicians may use the 59 modifier to indicate that the services described by two conflicting codes were performed in separate periods of time and are distinct form each other.
The 59 modifier is a clinical modifier since it takes a clinician to determine whether services were provided separately. It should be used judiciously and accurately, reflecting the distinct and separate nature of the procedures based on the specific circumstances of the patient encounter. Claims may be submitted without this modifier if services were not provided separately.
Active PT/OT NCCI Edits
Learn more about NCCI Edits by following the below links
Modifier Requirements
Understanding common modifiers that payers require PTs and OTs to use and applying them appropriately can help to reduce rejections and denials.
The purpose of modifiers is to provide additional information about a medical service or procedure without changing the core definition of the code. They help in specifying aspects such as the anatomical site, the type of provider who rendered care, and many other important details.
Common PT/OT Modifiers Payers Require
| Modifier | Description |
| GP | Service or treatment was delivered under a physical therapy care plan. |
| GO | Service or treatment was delivered under a occupational therapy care plan. |
| CQ | Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant. |
| CO | Outpatient occupational therapy services furnished in whole or in part by an occupational therapist assistant. |
| GT | Telehealth services provided via interactive audio and video telecommunications systems. |
| RT | Right Side (Generally used with strapping) |
| LT | Left Side (Generally used with strapping) |
Place of Service Codes
Choosing the correct Place of Service (POS) code is crucial in medical billing as it directly impacts reimbursement and compliance with insurance policies. Accurate POS codes ensure that claims reflect the appropriate setting where services were provided, which can affect payment rates and coverage eligibility.
Common PT/OT POS Codes
| POS Code | Description |
| 02 | Telehealth Visit: Patient in a location other than their home |
| 10 | Telehealth Visit: Patient is in their home |
| 11 | Provider's Office |
| 12 | Patient's Home |
| 99 | Other Place of Service (Typically used for work in a non-medical community space) |
Primary Diagnosis Problems
A primary diagnosis is the main condition or chief reason for a patient's visit to a healthcare provider, representing the most significant issue requiring treatment. Payers determine the primary diagnosis by recognizing it as the first code listed in the diagnosis section of a claim.
For physical and Occupational therapists, using injury codes as the primary diagnosis often leads to claim rejections because payers prefer to see the functional limitations being addressed during therapy sessions.
Injury codes can easily be identified by their leading S or T - payers accept these codes in secondary, tertiary or quaternary positions on the claim. You can review the full set of injury codes at the below link.
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