User Guide — Physical Therapy Billing

athenaClinicals

athenaClinicals provides features to make your physical therapy appointment and billing run smoothly.

Note: These features are independent of the Physical Therapy Episode feature.

 

With the Authorized Visit Alert feature, when a patient checks in for an appointment, a yellow warning message appears at the top of the Check-in page when the number of remaining prior authorized visits is running low.

 

You can contact the CSC to enable this feature. The threshold for warnings can be set from 1 to 5 remaining visits. The threshold setting is at the department level.

 

 

 

In physical therapy, it is common practice to bill based on the amount of time spent on a particular activity with the patient. Claims use "units" to describe the amount of time spent on a particular procedure.

 

By default, athenaOne calculates the units for physical therapy procedure codes using the Substantial Portion Methodology (SPM). You can contact the CSC to request that athenaOne use the 8-Minute Rule instead or that athenaOne dynamically calculate the PT units using either the SPM or the 8-Minute Rule, depending on the payer.

Note: To request a change to the calculation of PT units for your practice, contact the CSC by selecting Support > Create Case or Call in the Main Menu.

 

When the dynamic calculation of physical therapy procedure codes is enabled, athenaOne calculates PT units using either the Substantial Portion Methodology (SPM) or the 8-Minute Rule, depending on the payer.

  • When the patient has any Medicare insurance coverage (primary or secondary), athenaOne uses the 8-Minute Rule to calculate the units.
  • When the patient does not have Medicare insurance coverage or has no insurance coverage (that is, self-pay), athenaOne uses the calculation method that results in the greatest number of units. Physical therapy charges for commercial payers must not be less than physical therapy charges for government payers. Therefore, athenaOne uses the 8-Minute Rule to calculate units if SPM results in a lesser charge.

 

The Substantial Portion Methodology (SPM) calculates the units for each individual procedure code by dividing the time for the procedure code by 15. Then, SPM takes the whole number result for that procedure code and adds another unit if the remaining number of minutes is greater than or equal to 8.

 

For example, if the procedure code has 23 minutes, SPM calculates two units: 23 divided by 15 is 1 unit with 8 remaining minutes that can be counted as 1 additional unit.

 

 

 

The 8-Minute Rule calculates the units by dividing the time for each procedure code by 15. Then, it pools remaining minutes across all procedure codes before determining how to distribute the additional minutes. The additional minutes are given to the procedure code with the most remaining minutes.

 

If multiple procedure codes have the same number of remaining minutes, additional minutes are distributed based on their order on the Billing tab. If the Billing tab has only one procedure code, the remaining minutes are not counted toward the units.

 

For example, if one procedure code has 23 minutes, the 8-Minute Rule calculates 1 unit (23 divided by 15 = 1). If one procedure code has 23 minutes and another procedure code has 18 minutes, the 8-Minute Rule calculates 3 units, as follows:

  • 23 divided by 15 = 1, with 8 remaining minutes
  • 18 divided by 15 = 1, with 3 remaining minutes.
  • The total remaining minutes = 11 (8 + 3). These 11 minutes are allocated to the procedure code for 23 minutes because that procedure code had the most remaining minutes.

 

 

The 8-Minute Rule calculates billing units for physical therapy based on the number of 8-minute increments covered by the CPT code. For example, 15 minutes of Therapeutic Exercise (CPT code 97110) is equivalent to 1 unit for billing.

Units Number of Minutes
1 8 through 22
2 23 through 37
3 38 through 52
4 53 through 67
5 68 through 82
6 83 through 97
7 98 through 112
8 113 through 127

 

 

 

 

An info icon appears next to the PT unit calculation on the Billing tab. Click the icon to find out which method was used.

When the dynamic calculation method is enabled, the Units calculation information box shows you the resulting number of units using both methods, for example:

 

"Units calculated using the 8-minute rule. Using Substantial Portion Methodology results in 1 units."

 

 

 

 

Before you can convert minutes to units in an encounter, you must complete these setup steps.

  1. Add the CPT codes to your fee schedule using the Fee Schedules page. The following CPT codes are eligible for minutes-to-units conversion:
    • 97032 – 97036
    • 97110 – 97124
    • 97139
    • 97140
    • 97530 – 97542
    • 97799
  1. Add or edit a procedure template for the CPT code and select the Duration (minutes) option using the Procedure Templates page.
  2. Map each procedure code to the procedure template using the Order Type & Procedure Template Mapping page.

 

 

Note: If you change the patient's insurance after you save the Billing tab, athenaOne does not recalculate units for physical therapy.

  1. In the Exam stage of an encounter, locate the Procedure Documentation encounter section.
  2. Click show all.
  3. Check the box next to the procedure template to document.
  4. Enter the number of minutes the procedure should take.
  5. Enter data in the rest of the template as you normally would.
  6. In the Intake or Exam stage, add all appropriate diagnoses.
  7. In the Sign-off stage, click the Billing tab.
    The procedures that you documented have been added, with the appropriate number of minutes and units (for example, 30 minutes shows 2 units).

  8. Click Apply all ICD-10 codes to all services at the top of the Services section to add every diagnosis entered for that encounter to every CPT code currently on the Billing tab.

  9. Click Apply all ICD-10 codes, which appears inside the Services section at the top of each subsection where a CPT code has been entered, to add every diagnosis entered for that encounter to every CPT code in that section of the Billing tab.
  10. Complete the Billing tab as you normally would.
  11. Under Provider Review, select Billing Tab Review Complete after you complete your updates.
    A warning message may appear if:
    • The total number of minutes and units do not align. For example, if 97110 has 20 minutes associated with it and 97140 also has 20 minutes associated with it, then each translates to 1 unit each or 2 units total. However, the total number of minutes is 40, which is equivalent to 3 units. If you receive a warning, you can ignore it or update the units accordingly.
    • You approved more than 8 units total for the appointment. If you receive a warning, you can ignore it or update the units accordingly.
  12. Click Ready for Checkout.

 

 

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