Coding and Billing for Outpatient Rehab Made Easy

CHAPTER 1
and what the value of that code is. Verifying what therapy services an insurance plan
will reimburse for and what services are not covered is vital to proper reimbursement.
Therapy evaluations, aquatic therapy, group therapeutic procedures, and cognitive
therapy are a few examples of services not covered by all payers under a therapy plan
of care.
Note that, effective January 1, 2005, the Centers for Medicare & Medicaid Services (CMS)
no longer gives providers a 90-day grace period at the beginning of each year to use
deleted CPT codes while they load the new CPT codes into their system. This change
makes it even more important that facilities be familiar with the changes. 2 Check with
non-Medicare insurance carriers to determine whether they have a grace period when
new CPT codes are added and others are deleted.
❚❘❘ Timed vs. Untimed
There are two types of CPT codes:
• Time-based CPT codes—These codes require that the provider spend direct one-onone
time with the patient. Contact time ranges from 15–120 minutes in length
depending on the CPT code. Providers can bill multiple units of time-based
codes by the same discipline to the same beneficiary on the same date of
service. 3,4
• Procedure/Service-based CPT codes—Because procedure-based CPT codes are
untimed, providers can only bill one unit of a procedure-based CPT code per discipline
per beneficiary per session, regardless of the amount of time spent providing
that specific procedure or modality and regardless of how many areas of the body
are treated. These codes do not require direct one-on-one time, but the amount of
time a therapist spends performing the procedure is irrelevant because only one unit
can be billed per session. 4,5
2 © 2006 HCPRO, INC. CODING AND BILLING FOR OUTPATIENT REHAB MADE EASY