How to Use CPT Codes for Patient Education and Case Management?

As of 2024, the U.S. physical therapy industry is valued at $46.4 billion, with over 312,000 licensed therapists. The American Physical Therapy Association (APTA) highlights the growing use of remote physical therapy monitoring to manage chronic conditions and improve mobility. For US physical therapists and healthcare providers, mastering CPT codes is essential to streamline billing and ensure accurate reimbursement for these remote services.  

While there isn’t a specific patient education CPT Code, CPT Code 98960 can be used for patient training. In this article, you'll explore how CPT Code 98960 is incorporated into medical billing for patient education and case management, improving both outcomes and efficiency.

Understanding Patient Education and Case Management

CPT (Current Procedural Terminology) codes are used to standardize medical billing, making it easier for healthcare providers to communicate and track patient services. 

Specific CPT codes allow clinics to document patient education and case management services, capturing the educational support and interventions delivered to patients.

What is Patient Education According to the American Physical Therapy Association (APTA)? 

According to the American Physical Therapy Association (APTA), patient education helps your patients with the knowledge and skills they need to manage their conditions on their own and actively engage in their rehabilitation and long-term health. This includes providing services in circumstances where movement and function are affected by aging, injury, disease, or environmental factors. 

Physical therapy focuses on improving the quality of life through hands-on care, patient education, and prescribed movement. The ultimate goal of patient education is to promote optimal physical function, prevent the onset and progression of impairments, and improve the overall well-being of your patients, even without being physically present. 

Why Is It Important to Educate Your Patients? 

• Boosts Treatment Adherence: Educated patients are more likely to follow prescribed treatments, improving success rates.
• Improves Health Outcomes: Patients with a clear understanding of their condition and care plan achieve better recovery and long-term results.
• Reduces Risk of Complications: Proper education helps patients avoid mistakes that can lead to complications or setbacks.
• Fosters Patient Empowerment: Educated patients take an active role in their care, leading to more informed decisions and better self-management.

CPT Codes Applicable to Patient Education

When it comes to patient education CPT Codes in physical therapy it’s important to note that there isn’t a specific code designated solely for patient education. Instead, you’ll need to choose codes based on the nature of the service or physical therapy you provide. 

For patient education related to specific therapeutic activities, you can use relevant CPT codes like:

• CPT 98960: This code is used for billing patient education and training provided by a non-physician healthcare professional. It covers face-to-face, one-on-one sessions lasting 30 minutes, focused on teaching patients or caretakers how to manage chronic conditions like Hypertension, diabetes, asthma, or COPD, improving self-care and health outcomes at home.
  
  
• CPT 97110: This code applies when you provide therapeutic exercises aimed at increasing strength, endurance, or flexibility. For example, if you’re teaching patients exercises to improve their functional strength.
  
  
• CPT 97530: Use this code for therapeutic activities focused on improving functional performance. It would also be applicable if you were educating the patient on how to integrate these exercises into their daily routine.

These codes not only document the exercise or activity but also cover the educational aspect since patient instruction is inherent to these therapeutic services.

Watch this video on YouTube that talks about  2024 Remote Patient Monitioring: CPT Codes, Billing and Reimbursements, 

This video is nicely explained by Care Coordination Software by ThouroughCare on their channel and covers everything that you need to know about RPM CPT Codes as of 2024. 

Code Specifics for Individual and Group Sessions in Self-Management

For sessions focusing on self-management education, particularly when patients are learning how to manage chronic conditions, there are additional codes:

• CPT 98960: This code also applies to individual self-management training provided by an NPP (Non-Physician Practioner), typically billed in 30-minute increments. If you’re guiding a patient on managing their condition (e.g., diabetes or asthma), this would be relevant.
• CPT 99078: This code is specifically for group education sessions, where you might educate multiple patients simultaneously on managing their health conditions in a group session or a workshop. 

Suggested Read: Understanding Billing Units in Physical Therapy: A Guide to the 8-Minute Rule.

By selecting the correct CPT code, you ensure your patient education efforts are accurately documented and billed. Now, let's explore effective Billing Strategies for Patient Education to ensure proper reimbursement for your clinic. 

Billing Strategies for Patient Education

Billing Strategies for Patient Education are crucial to ensure accurate reimbursement for services provided. Here’s how you can approach it:

1. Use CPT Codes that Align with your Therapy or Services Provided: Relevant CPT codes like 97110 (therapeutic exercises) or 97112 (neuromuscular re-education) can be used to bill for educational services during therapy.
2. Accuracy in Medical Coding and Billing Practices: Accurate coding ensures appropriate reimbursement, minimizes claim rejections, and reduces the risk of audits by verifying your patient’s insurance. You might like reading about the Process of Verifying Patient Health Insurance. 
3. Billing Codes Based on Intent: Choose codes like 97112 for balance and coordination education or 97530 for functional activity training, reflecting the session's therapeutic intent.
4. Documenting Time-Based Education Sessions: Use time-based CPT codes (e.g., CPT 98960) for self-management education, ensuring documentation of time spent and patient participation.
5. Maximizing Reimbursement for Group Education: When conducting group sessions, use codes like CPT 99078, which covers patient education for groups, ensuring all services are billed efficiently.
6. Improving Remote Therapeutic Monitoring (RTM) Codes: For virtual patient education or remote monitoring, use CPT 98975-98977 for remote therapeutic monitoring, ensuring compliance with telehealth billing standards.

These strategies help ensure comprehensive billing for patient education while maintaining accuracy and maximizing reimbursement opportunities. 

Platforms like SPRY PT streamline billing for PT clinics with automated workflows, real-time eligibility checks, and error reduction. They also enhance accuracy and speed up reimbursements, making them the ideal solution for maximizing clinic revenue. Talk to SPRY here! 

Now, let’s discuss Case Management in Physical Therapy and its critical role in enhancing patient care.

What is Case Management in Physical Therapy? 

“Case management in physical therapy refers to the coordinated process of planning, assessing, and overseeing a patient’s care to ensure they receive the best possible outcomes.”

As a physical therapist, you play a crucial role in this process, helping patients navigate their treatment, adhere to care plans, and achieve optimal results.  The goal of case management is to improve patient care, reduce fragmentation, and ensure progress throughout the recovery process.

By managing all aspects of care, from treatment plans to follow-ups, you provide a higher level of support and ensure quality outcomes for your patients.

Strengthening Communication with the Patient’s Support Network

• Involves Multiple Parties: Effective case management requires communication between you, the patient, family members, caregivers, and other healthcare providers.
• Sharing Progress: Updates on the treatment plan and progress should be shared with all involved parties, including primary care physicians and specialists.
• Tools for Communication: Regular check-ins, written reports, and secure EHR systems, such as SPRY’s EMR, can streamline communication. For easy documentation, use AI-assisted SOAP notes. 
• Billing for Communication: Use CPT code 99366 (team conferences of med experts) to ensure multidisciplinary communication is billed correctly, improving care coordination and preventing conflicting advice. 

• Remote Monitoring: Use remote therapeutic monitoring tools to track patient progress between visits. This allows for real-time adjustments to the treatment plan and ensures consistent care. 

Let’s take an example to understand this better. Suppose a patient is recovering from knee surgery. During each visit, you’ll assess their range of motion, strength, and pain levels. Based on this data, you’ll adjust the treatment plan, increasing or decreasing exercises as appropriate.

Billing and monitoring progress can be done using CPT codes like 97001 (initial evaluation) and 97002 (re-evaluation), which allow you to document and bill for ongoing assessments of the patient's condition.

Additionally, using patient management software or EMR systems like SPRY PT can help you track patient outcomes and set automated reminders for follow-ups, ensuring no aspect of care is overlooked.

Billing Documentation for Education and Case Management

Proper documentation is important to ensure accurate billing and compliance with regulations. It also justifies the medical necessity of the services provided, ultimately protecting your practice and ensuring timely reimbursements. The basic requirements for documentation are mentioned below. 

1. Patient Demographic Information: Includes personal details like name, address, date of birth, and insurance information.
2. Medical History and Assessment Records: Documentation of the patient's health status, diagnoses, and care plans.
3. Physician’s Orders or Referrals: Written documentation from a physician outlining the required services or referrals for case management.
4. Treatment Notes and Progress Reports: Detailed notes of the services provided, patient progress, and any changes to the treatment plan.
5. Service Authorization Forms: Written authorization from the insurance provider or payer confirming coverage for the services rendered.
6. Encounter Forms or Superbills: Itemized forms detailing the services and treatments provided, including relevant codes for billing (CPT, ICD-10). You might like reading about What is a Superbill and How does it work in Medical Billing?
7. Educational Material Provided to the Patient: Documentation of any education offered to the patient regarding their care, treatment, or condition.
8. Case Management Documentation: Records outlining case management activities, including coordination of care and any follow-up.
9. Consent Forms: Signed patient consent forms for the treatments and services provided.
10. Explanation of Benefits (EOB): A document provided by the payer explaining what was billed, paid, or denied.
11. Insurance Pre-authorization or Prior Approval: Proof of any required pre-authorizations obtained from the insurer before providing services.
12. Billing Records and Invoices: Records of submitted claims and invoices for reimbursement. 

These documents ensure accuracy and compliance while justifying the medical necessity of services rendered for education and case management purposes.

Watch this video on YouTube about the CPT Coding Guidelines on Case Management Services.

This video is explained by Sai Shruthi on her channel, where she focuses on providing resourceful videos on medical coding. 

Demonstration of Skilled Service Linked to Plan of Care

To demonstrate skilled service linked to the plan of care, physical therapists (PTs) must document how their specific interventions, such as therapeutic exercises or manual therapy, directly address the patient's diagnosis and treatment goals. 

For instance, if a patient with a shoulder injury is treated with joint mobilization techniques, the PT can document increased shoulder range of motion or reduced pain after treatment. 

The PT should explain how this manual intervention supports the plan of care, justifying its necessity by showing the patient's improvement in performing daily activities like reaching overhead, which ties directly to the treatment goals. This clear documentation reinforces the skilled nature of the care provided. 

Responsibility for Documentation when Billing as Part of a Service 

• Link to Treatment Plan: Ensure documentation clearly ties patient education to the treatment plan and medical necessity.
• Detail the Type of Care: Record the specific type of care provided and how it supports patient outcomes.
• Use of CPT Codes: Apply appropriate CPT codes to reflect the service being billed.
• Monitor Patient Progress: Document measurable improvements and any necessary adjustments to the care plan.
• Justify Skilled Service: Explain the skilled nature of the intervention to validate the need for ongoing care.

Challenges in Billing for Patient Education and Case Management

Billing for patient education and case management presents several challenges, including the lack of specific codes and stringent documentation requirements, often complicating the reimbursement process for healthcare providers. Let’s break them down in a brief. 

1. Lack of Specific Codes: Direct patient education often lacks dedicated CPT codes, making billing complex. Hence, Use relevant Codes for the services you provide. 
2. Documentation Requirements: Extensive documentation is needed even when reimbursement is limited. 
3. Time Constraints: Time spent on education and case management may not always be reimbursable.
4. Compliance Issues: Ensuring all documentation meets strict billing regulations can be challenging.
5. Unclear Billing Guidelines: Vague guidelines for education services create confusion in proper billing.
6. Missed Reimbursements: Failure to document skilled services or adjustments can result in lost reimbursements. 

How does SPRY PT Help?

SPRY PT simplifies this process by offering EMR/EHRs, automating billing workflows, integrating CPT codes, and offering real-time error checks, ensuring that your patient education and case management efforts are properly documented and billed. It streamlines clinic operations, maximizing efficiency and revenue for PT clinics. Check out the Pricing here!

Conclusion

In conclusion, managing billing for patient education and case management in physical therapy requires careful documentation and overcoming various challenges. With solutions like SPRY PT, you can streamline these processes, reduce errors, and ensure accurate reimbursement. 

By automating workflows and integrating compliance, SPRY PT enables you to focus on delivering high-quality patient care while optimizing clinic efficiency and revenue generation. Book a Free Demo here!