Eli's Rehab Report

Question: When we bill an E/M code with CPT 97014 and 97124 for workers compensation or auto accident claims, we usually get paid for the E/M and one of the physical therapy (PT) codes, but the second PT code gets denied. Is there a specific combination of physical therapy codes that work and pay together with an E/M, or will any combination be denied?

Georgia Subscriber

Answer: Workers compensation insurance is governed by state laws, which vary depending on where your practice is based. Your denial could be based on a modality limitation, since some state laws limit the number of physical medicine modalities (97010-97039) and therapeutic procedures (97110-97139 and 97530) payable per visit.

Some state laws may have limits on the length of therapeutic procedures 97110-97542, limiting therapies to a maximum of 60 minutes per visit. The first step in investigating your denials is to contact the workers compensation insurer and investigate your state workers compensation billing guidelines for the E/M codes that you bill most often, 97014 (electrical stimulation [unattended]) and 97124 (massage, including effleurage, petrissage and/or tapotement).

Your denial could be related to modifiers depending on how your insurer dictates multiple PT billings, the second modality (and each modality thereafter) may require adding modifier -51 (multiple procedures).

If your investigation shows that the services are covered under workers compensation state law, you may overturn your denial by simply providing the carrier with the rationale or medical necessity that the physiatrist or therapist has documented for the denied therapy.