In 2019, Pinnacol implemented the Division of Workers’ Compensation Rule 18 change for time-based therapy codes. This applied to physical and occupational therapists and any providers that utilize time-based therapy codes.
Rule 18 states: The total of the billed unit time cannot exceed the total time spent performing the procedures in one session. Instead of looking at the time for each code individually, the total time for all therapies will be the maximum number of units to bill using the mid-point billing rule.
Per CPT guidelines, a unit of service is attained when the mid-point is passed. Documentation must include at least eight minutes of service to bill for a 15-minute visit. If the therapy/modality is between one and seven minutes, the service is not billable because the time did not exceed the mid-point for the 15-minute code.
Following the mid-point rule, the total time documented for billing will be based on the time intervals below.
Pinnacol's payment system reimburses the highest RVU services first.
Rule 18 states the maximum amount of time is one hour of procedures per day, per discipline, unless prior authorization is obtained from the payer. Procedures include therapeutic exercises, neuromuscular re-education, aquatic therapy, gait training, massage, acupuncture, dry needling of trigger points, manual therapy techniques, therapeutic activities, cognitive development, sensory integrative techniques and any unlisted physical medicine procedures.
Rule 18 also states there is a limit of two modalities, whether timed or non-timed, per visit, per discipline, per day. Modality codes begin with 970XX.
Examples of modalities are:
97010 - Application of a modality to 1 or more areas; hot/cold pack
97032 – Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 mins
We strongly encourage you to review how you are billing each unit of service. Please help us ensure correct payments by billing the correct number of units.
If you have questions, please contact us at 303-361-4950 or firstname.lastname@example.org.