Time-based therapy codes – units of service

The Division of Workers’ Compensation Rule 18 for time-based therapy codes was implemented in 2019. 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 is 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 midpoint for the 15-minute code.

Two examples of billing time-based therapy codes

Following the midpoint billing rule, the total time documented for billing will be based on the time intervals below.

Total time intervals for 1 through 5 units

Pinnacol’s payment system reimburses the highest RVUs services first.

Beginning in 2023, the maximum allowance for services billed by a physical therapist assistant or occupational therapist assistant shall be 85% of the fee schedule. The maximum allowance for services billed by a massage therapist shall be 72% of the fee schedule.

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.

Pinnacol conducts pre- and post-payment documentation reviews for therapy services. If your documentation does not support the services being billed, your request for payment could be denied or you could receive a letter requesting a refund based on an overpayment. If you have questions, please contact us at billingsuccess@pinnacol.com or 303.361.4940

Check here for PDF

Additional resources