Eli's Rehab Report

Question: Our office has both a physiatrist and a physical therapist working together. On occasion the doctor sees a patient during an office visit, for which we bill 99213 (office or other outpatient visit), and sends the patient to begin therapy with the physical therapist on the same day. The therapist performs an evaluation before commencing treatment, for which we bill 97002 (physical therapy re-evaluation). Our Medicare carrier, Xact, denies the 99213 provided by the doctor and pays for the 97002 provided by the physical therapist, saying that the 99213 is a component of the 97002. Although these two evaluations are for the same conditions, they are evaluations from different perspectives. Do you have any advice in billing for this situation.

Anonymous Pennsylvania Subscriber

Answer: Though the two evaluations are from different perspectives, neither Xact, nor most other Medicare carriers, will allow reimbursement for billing an evaluation and management (E/M) code on the same day as a physical therapy evaluation. However, if the physical therapist begins treatment on the same day that the physician bills an E/M code, you can bill for therapy and E/M, using modifier -25 to show that the E/M was a significant, separately identifiable evaluation and management service from the therapy being billed.

For example, if during the E/M the doctor discovers that the patient is experiencing a stiff knee (719.56) following a car accident and wants to immediately begin a therapeutic procedure (97110), he can bill the 99213 for the initial office visit with the modifier -25, followed by the 97110. The physical therapists evaluation would not be separately reimbursable.

Editors note: Patients being seen for initial physical therapy evaluation should bill using 97001. The 97002 code should be used only for physical therapy re-evaluations.

In some instances, however, the physician might be able to raise his code from a 99213 to a 99214, which reports more time spent with the patient, as well as a more complex medical decision. If the physician reviews what the physical therapist has done and the diagnosis justifies a physical therapy evaluation, assuming the physician is with the physical therapist for a major portion of the therapy evaluation, the physician could sum up the chart notes and include the therapists evaluation as part of the medical decision-making. This could allow the physician to bill the higher level of E/M, but its very important to note that medical necessity must justify the higher level. It is not enough for the physician to write a comprehensive report about the therapists evaluation and assume that he can therefore bill a higher level of E/M services. The chart notes must clearly show that the therapy evaluation was necessary based on the diagnosis.

Like most other providers, Xact requires all physical therapy claims to include the attending physicians name and the date the physician last saw the patient, and says that the treatment plan must be maintained in the patients file and subject to independent review. Xacts physical therapy medical policy states, Physical therapy and evaluation and management (E/M) services performed on the same day for the same patient must be medically necessary. The patients medical record must clearly document that a separate E/M service was performed in addition to the physical therapy treatment.