Mastering CPT Codes: Best Practice for PT and OT Billing

Accurate billing in physical and occupational therapy is essential for ensuring appropriate reimbursement, minimizing claim denials, and maintaining compliance with insurance carriers. A key element of this process is mastering the use of Current Procedural Terminology (CPT) codes, a universal language used by healthcare providers to report medical, surgical, and diagnostic procedures.

While physical and occupational therapy CPT codes provide clear guidelines, their improper use can result in significant financial losses and administrative burdens. This article highlights the most common CPT codes used in physical and occupational therapy, discusses frequent billing mistakes, and offers practical tips to avoid these pitfalls.

Understanding common CPT codes in physical and occupational therapy

In physical and occupational therapy, several key CPT codes are used frequently to describe interventions. These include:

• CPT Code 97110 – Therapeutic Exercise
• CPT Code 97112 – Neuromuscular Reeducation
• CPT Code 97530 – Therapeutic Activities
• CPT Code 97140 – Manual Therapy
• CPT Code 97116 – Gait Training

Each of these codes serves a distinct purpose and carries specific billing guidelines. Proper documentation and code selection are crucial for both accurate reimbursement and compliance with payer policies. 

Therapists often face challenges when determining the most appropriate code for their services, as many interventions may overlap across categories. Let’s take a closer look at how to avoid these challenges when working with physical and occupational therapy CPT codes.

Pitfall 1: Misclassification of therapeutic exercise (CPT code 97110)

Therapeutic exercise (97110) is perhaps the most commonly billed CPT code. This code is intended to cover exercises aimed at improving strength, endurance, range of motion (ROM), and flexibility. It includes interventions such as active or passive ROM, stretching, resistance training, and strengthening activities. Therapists sometimes fall into the trap of overusing this code, lumping a wide variety of interventions under it—even when other codes would be more appropriate.

For example, exercises involving balance, coordination, and proprioception may more accurately be billed under 97112 (Neuromuscular Reeducation). Using 97110 for neuromuscular interventions can result in underbilling and potentially trigger audits or denials if the services provided don’t align with the documentation. To prevent this, always ensure that the specific intervention matches the definition of the CPT code used.

Pitfall 2: Misunderstanding time-based codes

Another common pitfall is misunderstanding time-based CPT codes, particularly when it comes to tracking one-on-one time with patients. Codes like 97110, 97112, and 97530 are all time-based, meaning they are billed in 15-minute increments. These codes require direct, one-on-one contact between the therapist (or assistant) and the patient.

Therapists must keep a careful log of the exact time spent delivering direct services to each patient. For instance, if a therapist works with a patient for 25 minutes on therapeutic exercise (97110), they can bill for two units of this code (each unit covering 15 minutes). However, billing for more time than was spent one-on-one can lead to overbilling, audits, and possible repayment demands.

One common misconception is that time spent supervising patients while they perform exercises independently counts toward billable time. This is incorrect. Supervised or self-directed exercises, without active involvement by the therapist, should not be billed as direct patient care. Accurately tracking time spent delivering skilled therapy is crucial for avoiding billing errors.

Pitfall 3: Overuse of therapeutic exercise vs. functional activities

Therapeutic exercise (97110) is often overused when therapists could be billing for therapeutic activities (97530), especially when the focus of therapy shifts from improving strength and range of motion to more dynamic, functional activities.

Therapeutic activities (97530) involve dynamic activities designed to improve functional performance. These activities include bed mobility, transfers, lifting, carrying, and other functional tasks aimed at improving the patient’s ability to perform daily activities. The use of 97530 is especially common in occupational therapy and should be utilized when therapy involves activities that improve a patient’s ability to function in everyday life, such as practicing transfers or car simulations.

Billing 97110 for functional activities may result in under-reimbursement, as 97530 typically reimburses at a higher rate. To prevent this, therapists should familiarize themselves with the definitions of both codes and ensure they bill appropriately based on the activity performed.

Pitfall 4: Group therapy vs. individual therapy billing

Another common billing challenge involves distinguishing between group therapy (97150) and individual therapy. Code 97150 is untimed and used for group therapy, which is defined as two or more individuals receiving therapy services simultaneously. Many therapists unintentionally bill individual therapy codes, such as 97110 or 97530, when working with multiple patients at the same time.

To appropriately bill for group therapy, you must provide skilled interventions to two or more patients concurrently, without delivering substantial one-on-one time to any individual during the session. If significant one-on-one time is spent with each patient, then individual therapy codes should be used. Properly distinguishing between these services ensures compliance with payer policies and prevents potential billing discrepancies.

Best practices for avoiding CPT billing errors

Struggling to streamline your billing processes with physical and occupational therapy CPT codes? Here are some practical strategies to keep you on track. Implementing these best practices can help you improve accuracy, avoid costly errors, and ensure correct reimbursement for the services you provide.

• Document Thoroughly: Keep detailed records of all interventions provided. These records should describe the therapy administered, the time spent, and the patient’s progress. Thorough documentation helps to justify the CPT codes billed.
• Match the Code to the Intervention: Always select the code that best describes the therapy intervention provided. Avoid lumping different activities under a single code like 97110. Accurate coding is essential for correct reimbursement.
• Track Time Meticulously: For time-based codes, ensure that the recorded time reflects only direct, one-on-one therapy. Time spent supervising a patient or when the patient is performing exercises independently should not be billed as therapy time.
• Review Payer Policies: Each insurance carrier may have unique requirements for how specific CPT codes should be billed. Make it a habit to review these policies regularly to ensure compliance with their guidelines.

By following these best practices, you can reduce errors, avoid denials, and optimize reimbursement for your services.

Take your billing to the next level with expert CPT coding

Navigating physical and occupational therapy CPT codes can feel overwhelming, but mastering their use is crucial for accurate billing and reimbursement. Avoiding common pitfalls—like misclassifying services or misunderstanding time-based codes—will help you streamline your billing process and reduce costly mistakes. 

For those looking to improve their CPT coding skills, my course, Common CPT Codes: PT and OT (97110–97763), offers a deeper dive into the nuances of CPT coding. In this course, you’ll learn not just the technicalities of the codes, but how to choose the most appropriate one based on your documentation and the true intent of the intervention. We’ll break down CPT codes 97110 to 97763 with real-world examples, making navigating challenging coding decisions easier. If your goal is to reduce denials, ensure compliance, and optimize your reimbursement, this course will provide you with the practical tools and insights you need.