Reporting 'incident-to' under a physician's PIN may flag an audit
If you think you know 97001-97004 backward and forward you may be surprised that you should avoid using E/M codes for physical therapists (PTs) and occupational therapists (OTs). However you can report 97001-97004 in addition to a separate E/M service on the same day.
97001 97003: Check the Scope of Practice
First avoid using the E/M codes for physical therapists and occupational therapists. If a practice codes a PT's or OT's services under a physician's PIN as incident-to the carrier would likely pause before reimbursing the claim.
Medicare requires that ""independently practicing physical therapists are limited to physical therapy CPT
HCPCS codes only "" under the Medicare Part B Billing Manual for Physical Therapy.
PTs can use 97001 (Physical therapy evaluation) to report their initial evaluation of the patient which should occur before either the PT or the physician establishes the plan of care. OTs should use 97003 (Occupational therapy evaluation).
The physical therapy evaluation which normally pays about $70 returns higher payments than a doctor's E/M services which pay about $30 to $40 for 99212 (Office or other outpatient visit for the E/M of an established patient ...). That means that reporting 97001 under a doctor's PIN may look like a tactic to glean more money and red flag a possible audit.
Note: Initial evaluations for therapists practicing in skilled nursing facilities (SNFs) must occur while patients are staying in the SNF so the therapist can evaluate their conditions accordingly. Therapists cannot use a plan of treatment that may have been previously developed for the patient while in a hospital.
CPT 97002 and 97004: Use Them Sparingly
For re-evaluation services PTs can report 97002 (Physical therapy re-evaluation) and OTs can report 97004 (Occupational therapy re-evaluation) as long as the therapist uses the time spent to evaluate a change in the patient's condition.
Warning: PTs and OTs should be careful not to use 97002 or 97004 every time the therapist treats the patient following the initial evaluation. Although OTs will informally re-evaluate patients as part of each treatment you should use the re-evaluation code sparingly says Judy Thomas MGA reimbursement policy director at the American Occupational Therapy Association.
""A physical therapy re-evaluation may be required every 30 or 60 days according to state law as part of the physician's order for continuing care "" says Jean Acevedo LHRM CPC CHC senior consultant with Acevedo Consulting in Delray Beach Fla. ""However most payers (including Medicare) will only pay for 97002 if there has been a significant change in the patient's condition or treatment plan - such as a patient who suffers a stroke or serious fall which requires that the PT adjust the plan of treatment [...]