Physical Therapy Documentation: Why Intent Matter

The average PT clinic may lose out on over $20,000 a year per therapist because of poor Physical Therapy documentation and selecting the incorrect CPT codes for billing.   One of the biggest areas for improvement in Physical Therapy clinics is to make sure therapists are documenting correctly and billing appropriately for services they are already performing.

Physical Therapy treatments often include a variety of techniques, skill, and individualized focus to improve movement patterns and to reduce pain.  As trained professionals, our course of treatment should demonstrate a progression from low complexity to higher complexity throughout the POC.

By identify the underlying reason you are doing a motion or activity, you identify the intent of your treatment.  You should choose your CPT codes based on the intent or rational you’ve identified for performing the treatment.

While several exercises and activities can be justified under multiple CPT codes, it doesn’t mean we should default to 1 or 2 codes for every treatment performed that day.  

Remember, it comes down to your intent.  A single activity may have more than one CPT code during the plan of care.

PT Documentation Example

Here’s an EXAMPLE:

Example: Squatting

What is your intent as a therapist?

Ther Ex =  Intent to strengthen the quads

Therapeutic Activity = Intent to improve sit to stand transfers

Ex. Quad sets:

What is your intent as a therapist?

Therapeutic Exercise = Intent to strengthen the quads in the presence of good motor control

Neuro Re-education = Intent is to improve strength through improving motor control of the lower extremity

Progression from low to high complexity

As we progress our patients, the skill level required changes.  Early on, it makes sense to focus on low level complexity items such as stretching or basic strengthening exercises.  As we progress with the patient, we challenge them to use multiple muscle groups correctly, focus on precise joint motion, and specific recruitment of muscles to facilitate proper motor control and timing.  When our intent is to improve these elements, our selection of the CPT code should reflect this.

Below is a short list of CPT codes and the corresponding skill level required by the patient to perform each item:

How much skill does the patient require to perform these tasks:

Ther ex: Low complexity by the patient

Aquatic therapy: low complexity by the patient

Manual Therapy: moderate complexity by the patient

Gait Training: higher complexity by the patient

Neuro Re-Ed: higher complexity by the patient

Therapeutic Activity: higher complexity

If we provide treatment that is skilled and progressive, our documentation should reflect the skilled treatment we are already providing.

Too many Physical Therapist default to charging 2 units of Therapeutic Exercise and 1 unit of Manual Therapy for every patient.

So, why is Therapeutic Exercise the #1 billed CPT code in our clinic?

Some have suggested that it’s because of habit; others feel it’s a safe bet for insurance audits. Still others admit that it’s comfortable to just mark the treatment as Ther Ex. instead of trying to justify something more complex.

Remember, justification for the use of Neuromuscular re-ed instead of Ther. Ex stems from your intent.  So if your intent is to improve someone’s coordination with squatting and to improve stability through balance training and targeted recruitment of the glutes – that’s Neuromuscular Re-Ed!  Documenting your treatment as TherEx would be a misrepresentation of your skill level and intent.

Choosing a CPT Code

Therapeutic Exercise:

Big Picture: Used to address a specific parameter that limits function. (ROM, strength, endurance)

Therapeutic Exercise is used to address

  • Strict weakness of a muscle (strength / endurance)
  • Decreased ROM and flexibility
  • Focused on a single measurable parameter

Neuromuscular Re-ed

Big Picture: Used in preparation to lead into therapeutic activity

(You are likely performing Neuromuscular Re-Ed and Therapeutic Activities for > 50% of your treatment.  You can and should bill for this.)

Neuromuscular Re-ed is used to address:

  • Poor ability to recruit muscle with motion (facilitation)
  • Difficulty with timing of muscle recruitment
  • Poor motor control and sequencing
  • Decreased stability and balance
  • Lack of coordination
  • Nerve palsy resulting in muscle flaccidity or weakness (L4-5 impingement/compression; Radial n. palsy)
  • Posture and proprioception in sitting and standing

Therapeutic Activity

Big Picture: “Dynamic Activities to improve functional performance of a specific task.”  Think of tasks as things ending in “ing”

Training to perform a specific task: ascending/descending stairs, squatting to chair, reaching to shelf, gripping, pulling, pushing, pinching, lunging, stepping over, throwing, lifting overhead, opening

  • Activity must connect the impaired performance to the condition. (i.e. don’t work on squatting if not part of diagnosis for finger fracture)
  • Training in proper body mechanics for activities

Financial Considerations

Selecting CPT codes based on your intent will reflect your skill and expertise.  Insurance companies will reimburse us for our skill level in our treatment.  

Each CPT Code is reimbursed at a different rate within payers and between payers.  In general, the more complex the CPT code, the higher the reimbursement.

As we progress our patients through the different levels of complexity within our plan of care, it makes sense that our reimbursement reflect this difference.   

Here’s an example of a treatment:

The therapist intends to improve motor control and stability of the patient with overhead lifting.  She performs joint mobs to improve the glide of the GHJ, PNF diagonals to promote sequential firing of the scapulohumeral stabilizers, and supine serratus punches to increase the activation of the upward rotators of the scapulae.  She includes theraband exercises to promote strength of the rotator cuff.

Let’s compare the choice in CPT Codes: (Assume Medicare Rates for Michigan)

1 MT ($20.95) + 2 TE (29.33+22.82) =  $73.10

1 MT ($20.95) + 1 TE (22.82)+ 1 NM ($33.34) =  $77.17 (5.5% increase)

As your treatment continues to progress and advance, your selection of CPT codes may even evolve to include the following:

2 NM (25.69 + 25.69) 1 Ther Act (38.43) = $89.81 (a 22% increase)

Again, this is simply a reflection of your original intent to provide advanced and skilled treatment throughout the patient’s plan of care.

You haven’t changed your intent for treating this patient with shoulder pain and instability, but you have changed the way you are reimbursed.  Even if it resulted in a 12% increase in reimbursement for your clinic, the change could result in an increase of over $20,000 per therapist in a 12 month period. Run the numbers and see what a 10-12% increase in net revenue per patient looks like for your clinic. It’s worth taking the time to do your documentation correctly!

Tim Fraticelli, DPT Physical Therapist

Tim Fraticelli is a Physical Therapist, Certified Financial Planner™ and founder of He loves to teach PTs and OTs ways to save time and money in and out of the clinic, especially when it comes to documentation or continuing education. Follow him on YouTube for weekly videos on ways to improve your financial health.

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