Insurance billing for therapists: the claim a therapy practice sends, from the session code and the units to the EOB and the patient balance, for the therapist who bills their own practice

Before the visit: eligibility, the benefit and the authorization

Every insurance denial that was avoidable was avoidable here. The plan is checked for the date of service: is therapy a covered benefit, how many visits a year, is a referral or a prior authorization required, what are the deductible and the copay today. The answers go on the register against the patient's plan, and the front desk collects the copay at the visit. A therapist who bills without this step is billing to find out, and the finding out arrives as a denial six weeks later.

The note into the claim: codes, units and the plan of care

For physical and occupational therapy the timed minutes across the timed codes become units under Medicare's 8-minute rule, which the free billing units worksheet on this site works from the minutes; a unit needs at least 8 minutes documented. For mental health the session length picks the code and the authorization number goes on the claim. Medicare's benefit policy manual describes the plan of care and the documentation a therapy claim rests on, and the claim goes out as an 837 through a clearinghouse or on the CMS-1500 on paper.

The EOB posted against the claim, line by line

When the remittance arrives, each claim line is reconciled: the charge, the allowed amount, the contractual adjustment, the deductible and coinsurance applied, the payer's payment. The EOB reconciliation worksheet here works one line and shows the check that payment, patient share and adjustment add back to the charge. Posted line by line, the patient statement is right; posted as a lump, nobody can say why the patient owes what the statement says.

The denial worked, and the deadline it has to beat

A denied line carries a reason code, CO 16 for missing information, CO 96 for non-covered, CO 252 for an attachment wanted, and a remark code that says what to do. The corrected claim or the appeal goes out against the filing limit, which for Medicare is 12 months from the date of service under 42 CFR 424.44 and whatever the contract says for commercial payers. The register records the denial with its date and code so it is worked that week; the claims cycle worksheet shows the denial rate all of this produces.

The Medicare plan of care, and the dates the claim rests on

A Medicare therapy claim stands on a plan of care the treating therapist writes at the evaluation and the physician or non-physician practitioner certifies, with the certification expected within thirty days of the plan and a recertification at least every ninety days while treatment continues. The progress report is due at least once every ten treatment days. A claim for a date of service outside a certified plan comes back as a denial for the whole episode rather than for one visit, which is why the register keeps the plan's start, certification and recertification dates against the patient and why the front desk reads them before the visit, not after the remittance.

The modifiers a therapy claim carries

Every Medicare therapy line carries the discipline modifier, GP for physical therapy, GO for occupational, GN for speech, and the payer's edits reject a timed code without it as CO 16. Once a patient's therapy spend passes the annual threshold, the KX modifier attests that the services remain medically necessary and the documentation supports them, and a line above the threshold without it is denied. Where two timed services that the bundling edits treat as one were genuinely distinct, the modifier the edit allows separates them, with the note to show it. The register keeps the modifiers as billed against each line, so the CO 16 for a missing GP and the CO 234 for a missing separating modifier are patterns the practice can see rather than surprises it keeps receiving.

A mental health claim, worked from the session

A fifty-five-minute session is the 53-minute-and-over psychotherapy code; a forty-minute session is the 38-to-52 code; a thirty-minute one the 16-to-37. The evaluation at the first visit is its own code. The authorization number goes on the claim with the visits remaining counted down on the register, and the place of service says whether the session was in the office or by video, with the telehealth modifier the payer requires. The claim goes out; the remittance comes back with the allowed amount for the session code and the client's copay applied. Posted line by line, the client's statement says which session they owe for; posted as a lump, it does not, and a client who cannot see the working of a statement stops paying it.

The patient statement, and why it is right only if the posting was

The statement is the last step of the cycle and the only one the patient sees. It lists each date of service with the charge, the payer's payment, the contractual adjustment the patient never owed, and the deductible, coinsurance or copay that is theirs, then the balance. Every line of it comes from a posted remittance line, which is why the EOB reconciliation worksheet on this site insists the posting balances back to the charge before it is done. A statement that shows a balance nobody can trace to a visit is the one that produces the phone call, the dispute and the write-off; a statement built from balanced lines is the one that gets paid.

A week of billing for a two-therapist practice, as the register runs it

Monday: the register lists the visits from last week that have no claim yet, and the biller builds them from the notes, counting the units on the worksheet and reading the plan-of-care dates before each one goes. Tuesday: the clearinghouse report shows two rejections for a subscriber number, fixed from the card scanned at the front desk and resent the same morning. Wednesday: an 835 arrives covering nineteen claims; each line is posted, three CO 45 adjustments and one CO 16 with its remark code go on the register. Thursday: the denial queue, oldest first, with the corrected claim for the CO 16 and a phone call on a CO 252 sent a month ago. Friday: statements run from the balances for the patients whose remittances posted this week, and the eligibility checks for next week's new patients. None of that needs a billing department; all of it needs the register to be the list.

Questions people ask about insurance billing for therapists

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