How to Bill for Pain: Physical Therapy CPT Codes for Pain Management Procedures

It has been reported recently that over 100 million people in the US are currently struggling with persistent pain. The US figures show us that 1 in 4 people in the US are suffering with persistent pain. The global trend is 1 in 5.

Let that sink in for a moment as a clinician… 20% of the world’s population has some form of persistent pain. Combine that with the fact that 30% of chronic pain never had a physical cause for its onset and you can see that the pain epidemic upon us is very complex and it is puzzling many clinicians. Do we have a pain epidemic on our hands? Absolutely! Is there another way to approach such a conundrum…? Glad you asked, this is where the story gets exciting and hopeful.

The frustration of treating chronic pain as a physical therapist is comparable to other medical fields. We are all “in the trenches” trying to help people the best we can based on the training we have. We may know that teaching people about why they hurt is supported in the evidence, but how exactly do we do it? Can I bill for talking with a patient? If so, which CPT code should I use and do I have to hit 8 minutes to be able to bill for my services? How well is Pain Neuroscience Education (PNE) reimbursed?  

Pain Is An Expensive Problem Worth Solving

Over 600 billion dollars is spent each year in the United States in the treatment of chronic pain. That is a huge market of patient who could benefit from physical therapy services, especially with the research showing a cognitive-behavioral focused physical therapy plan of care, blending PNE with graded exposure, sleep hygiene, and realistic goal setting is more effective in the long term than the invasive and risky procedures that are implemented on a daily basis. So you might be thinking… how do I help these people and get them in my doors for therapy?

A new commentary from JOSPT in May of 2018 Titled “Physical Therapists Role in Solving the Opioid Epidemic” stated that the first thing we all need to do is get better at educating our consumers. Well, you can’t educate your potential consumer until you understand the neuroscience and neurobiology of chronic pain yourself. There is a bit of an “iceberg effect” where as a clinician you need to know a lot of information about the neuroscience of pain (all the surface area of the iceberg under the surface of the water) in order to answer the questions about pain that your patients have (the “tip” of the iceberg).

The data from RCTs and Systematic reviews is pretty clear that when people understand more about the neurobiology and neurophysiology of why they hurt they end up with superior outcomes compared to usual care. In fact, the results of an updated systematic review of Pain Neuroscience Education for musculoskeletal pain provided strong evidence for pain science education improving pain ratings, pain knowledge, disability, pain catastrophization, fear-avoidance, attitudes and behaviors regarding pain, physical movements, and healthcare utilization (Louw, Zimney, Puentedura, and Deiner, 2016).

Effective Pain Treatment Starts With Education

We must be better at educating the public about what we can do for their pain and how there are less barriers to coming to see us than they realize.

Gone are the days where we can rely on the gatekeeper for a constant influx of referrals. We must offer direct-to-consumer marketing via community wellness talks, social media posts, community events, newspaper articles, etc. so that patients suffering from chronic pain know that there is hope for them and that physical therapy has a role to lead the charge moving forward.

The caveat is that there is only so much money in the Therapy Cap each year so we as providers want to be cost effective and really work on instilling an internal locus of control and working toward wellness strategies by empathetically meeting people where they are at and compassionately coaching them along their journey of recovery by equipping them with evidence-based education and positive lifestyle/coping strategies involving exercise, stress management, sleep hygiene, etc.  

The Therapeutic Pain Specialist (TPS)

To help you better understand the neuroscience of pain and how it relates to your practice, the International Spine and Pain Institute has created a structured Therapeutic Pain Specialist (TPS) program that culminates with a certification that you can actively use to market yourself to the community (your potential consumers), as well as referral sources. You can even market yourself to local business in your area and show them that they have a vested interest in healthcare whether they know it or not because they have a vested interest in their workforce and keeping them healthy and productive. The best way to treat chronic pain is to prevent it and as a TPS you might be able to partner with businesses and work toward health and wellness and have access to a market that you would otherwise never see!

The Business of Chronic Pain

As part of the TPS certification, we run a course called “The Business of Chronic Pain.” In the course we dig deeper into the costs associated with chronic pain as well as help you to understand how to bill for your services.

Because there is scientific evidence that there is a change within the session of reduced cortical processing of a noxious input following PNE, the most reasonable CPT code to use for billing for your educational time is 97112 Neuro Re-Ed.

This makes sense! If we can take a brain that is fearful and producing pain to protect and calm down in a session of PNE by making the “unknowns known,” then we just changed the nervous systems processing of threat… we re-educated the system, thus neuro re-ed is the code that makes the most sense.

The written rationale that you use when billing Neuro Re-ed is very important as well, and again, we have you covered. We have written verbiage that you can use when documenting which PNE story you used so that your billing is accurate and justifiable.  

Learn more about the Business of Chronic Pain in the Therapeutic Pain Specialist certification

Common Physical Therapy CPT Codes For Pain Management

The most commonly used physical therapy CPT codes for a plan of care utilizing a pain science educational approach are:

CPT 97112 Code – Neuromuscular Re-education: RVU = .78 per 15 minute unit to 1 or more body area(s). CLINICAL: Improve movement, balance, coordination, kinesthetic sense, posture and/or proprioception for sitting and /or standing activities.

Within the PNE approach, we know via fMRI studies that there is a drastic within session change involving cortical processing of the same noxious threat following PNE. Thus, we are altering the nervous system and it makes the most sense to bill PNE under the 97112 code.

CPT 97110 Code – Therapeutic Exercise: defined as Therapeutic exercises to develop strength and endurance, range of motion, and flexibility

Typically speaking, getting people going on walking programs to improve their endurance for ADLs and to improve the endogenous analgesic effects would fall under 97110.

CPT 97530 Code – Therapeutic Activities: defined as Dynamic activities to improve functional performance, direct (one-on-one) with the patient (15 minutes)

Here is where we thrive as PTs, right?! We are function experts! Any activity that we are working on to improve someone’s functional performance for activities encountered in day to day lift would be appropriate here. For example, if someone had significant fear avoidance regarding lifting due to fear that they would hurt their back, then taking them through graded exposure to lifting so that it becomes less feared would fall under 97530.

 

Billing for Pain FAQs

How do I bill for talking to a patient about pain?

If you are using PNE dialogue with the intent to address maladaptive beliefs and improve function, there is good rationale that this should be billed under 97112 because we are CHANGING THE NERVOUS SYSTEM with our cognitive and behavioral focused education. We do need to take into account that we need to respect billing rules and be engaged in PNE for 8 minutes to bill a unit of 97112. We also need to keep in mind the 8 minute rule for Medicare patients where we need to be delivering the treatment for 23 minutes to bill a 2nd unit, 38 minutes to bill a 3rd unit, and 53 minutes to bill a 4th unit.

Is PNE well reimbursed?

I don’t know if this is the right question to ask when we are dealing with trying to help someone suffering from chronic pain. I believe the question we should be asking is “what is the best treatment for this patient?” I do however get it that as a business owner, we do need to look at receipts and be aware of changes in reimbursement and how it affects the ability to run a business.

To the best of my understanding, reimbursement rates for CPT codes vary by geographical location so it would be best to look up reimbursement rates in your area for this answer. For more information on billing and coding, see the APTA’s website.

What do I need to know about Medicare and pain treatment?

Under Medicare guidelines, prospective patients with Medicare insurance may present to a physical therapist via direct access and have an evaluation performed. If that evaluation is then signed off by the primary care physician, the patient can continue on with treatment under the management of the attending physical therapist.

Get Certified and Incorporate Pain Neuroscience into your Physical Therapy Practice

The data shows there is a HUGE subset of patients that need pain treatment and related services. Grow your practice and give people hope at the same time. Join us at ISPI and get trained so that you are prepared to help the 25% of US population that desperately needs you. Your next patient is waiting.

Get Started With the Therapeutic Pain Specialist certification

8 responses to “How to Bill for Pain: Physical Therapy CPT Codes for Pain Management Procedures

  1. Serena Curler says:

    Can non physical therapy providers use this teaching code?

    1. Steve Goldrick says:

      What health professional are we talking about?

    2. Scott Tesoro says:

      I am a DC and have used 97110 and 97112. These are medical CPT (procedure) codes and are not exclusive to only PTs.

      1. Steve Goldrick says:

        Absolutely Scott. Sorry if I gave the vibe that these are only for PT’s, I certainly didn’t intend that. Glad to see they worked on your end as well. Thanks for chiming in!

  2. Phil Gainan says:

    Thanks for the article, I do believe I will look into Pain Specialist

  3. Steve Goldrick says:

    Thanks Phil, I am glad you enjoyed the article. If you have any questions about the program content, cost, and how to make it all come to fruition for you and your clinic, I am an open book. You can reach me at goldricksteve@gmail.com

  4. Hi Steve:
    I have a clinic..which our medical physician do primary care. But our physician states he does want to very very chronic pain clients. We are wellness. We are trying get clients off the meds..we have massage therapist that want to do massages in areas they have have pain..We want to help people to get off the Opioid Epidemic. What can I do as a business. I care! Our Doctor care. Can you guide me in a direction to get referrals for our doctor? We are wellness…to help get off the meds..

    1. Steve Goldrick says:

      Hey Pamela! Thank you so much for your comment. We absolutely have to tools to get you and your clinic going in the right direction with helping people in pain. Given that it sounds like there is a multi-disciplinary group around you, perhaps getting everyone on the same page might be the best way to go. I would encourage you to contact Kelly Isbell, PhD with Evidence in Motion (partner with ISPI) at her email kelly@eimpt.com to see if we at ISPI can help set something up for your clinic. We have all the tools to help you get there. Excited for you and I appreciate that you care and want to get better.
      – “Education is Therapy” :)

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