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Physical therapy professionals may find it difficult to distinguish between Habilitative and Rehabilitative Physical Therapy (PT) billing. Just when you thought things couldn’t get any more confusing, you find that habilitative and rehabilitative services must be billed separately. When it comes to billing, there’s a lot to consider, from constantly changing claims modifiers to continuing adjustments to federal regulations.

Physical therapists and therapist assistants must grasp the differences between Habilitative and Rehabilitative Physical Therapy (PT) treatments, as well as how to meet provider reporting standards, to receive the right reimbursement from payers. Let’s go over the Habilitative vs Rehabilitative Physical Therapy (PT) difference and when to use the proper claims modifiers.

Habilitative vs Rehabilitative Physical Therapy (PT) Billing Differences

Difference Between Habilitative vs Rehabilitative Physical Therapy

Although they are frequently used in conjunction, there is a difference between habilitation and rehabilitation in physical therapy. A thorough understanding of the distinction between the two is required for proper navigation of the documentation and billing processes.

 

Habilitative Therapy

To put it simply, habilitative therapy assists patients in DEVELOPING skills.

Habilitative therapy refers to services that assist patients in learning, maintaining, and improving common skills that were not acquired at an age-appropriate level but are required for daily living.

 

Rehabilitative Therapy

To put it simply, rehabilitative therapy assists patients in RESTORING functions.

Following an illness or injury, rehabilitative therapy consists of a variety of services that aid in the restoration and improvement of health functions and skills required for daily living.

 

Habilitative and Rehabilitative Physical Therapy (PT) Services May Involve the Same Approaches

It’s important to distinguish between habilitative and rehabilitative physical therapy services because the two can involve the same approaches. Even in patients with different diagnoses, both rehabilitative and habilitative PT services can address the same functional outcomes.

The difference between the two care plans is that the treatment goals for each vary due to the specific injuries and conditions that the patients are dealing with. As a result, while the interventions are the same, one is habilitative and the other is rehabilitative.

Habilitative vs Rehabilitative Physical Therapy (PT) Billing Differences

Despite having a thorough awareness of the differences between habilitative and rehabilitative treatment services, therapists must also know how CPT codes apply for reimbursement. To fully understand why these services are paid separately, it is necessary to analyze the 2017 federal law that imposed distinct visit limitations for habilitative and rehabilitative services to provide equal coverage.

How Does the CPT Code Apply To Rehabilitative and Habilitative Physical Therapy?

The Centers for Medicare & Medicaid Treatments (CMS) established modifiers 96 and 97 on January 1, 2018, to replace the SZ modifier, which was previously used by physical therapists to represent habilitative services.

The differences between modifier 96 vs. 97 are as follows:

Modifier 96 is used to identify habilitative services and procedures.Modifier 97 is used to identify rehabilitative services and procedures.
Modifier 96 is also to be used if habilitative services rendered can be considered either habilitative or rehabilitative.Modifier 97 is also to be used if rehabilitative services rendered can be considered either rehabilitative or habilitative.

 

Insurance companies are increasingly requiring the use of these modifiers, so keep an eye for any changes in the future.

When reporting these modifiers to a health plan provider, Physical Therapy (PT) providers should additionally provide documentation indicating the services provided are to help a patient in learning something new or recovering a lost function. Providing an adequate explanation for the modification listed improves communication of the patient’s treatment plan and eliminates billing delays and inaccuracies.

Showing Service Type in Documentation

As always, accurate documentation is essential for compliance. Because there may be overlap and patients who receive both types of treatments, it is critical to document what you are delivering and the purpose behind that care. This will become increasingly essential as more insurance companies begin to use these modifiers.

Is it possible for a patient to receive both types of services?

It’s also important to note that, in some instances, patients can receive Habilitative and Rehabilitative Physical Therapy (PT) services.

To Whom Does This Apply?

Finally, when handling Habilitative vs. Rehabilitative Physical Therapy (PT) Billing, keep in mind that not all health insurers will use distinct visit limits for billing, as indicated above. Individual and small group plans that comply with the Affordable Care Act (ACA), Medicaid managed care, and individuals who have just become eligible for Medicaid due to expansion are required to give distinct visit limitations.

Self-funded small and large group health plans, grandfathered health plans, conventional Medicaid, and Medicare are exempt from the visit limit requirement. With such a disparity in criteria, Physical Therapists (PT) should always contact payers to understand visit restrictions for each type of service, as well as their specific approach for modifiers 96 and 97.

Ongoing changes in coding can be quite a challenge. To help avoid costly errors with your billing documentation processes, work with trusted billing service providers that work hand-in-hand with scheduling modules to ensure each patient visit is billed correctly. Don’t slow down your reimbursement with confusion over Habilitative vs Rehabilitative Physical Therapy (PT) Billing processes. Zee Medical Billing can help simplify and safeguard your billing and documentation.

Get a free no-sting attached billing services quote from ZEE Medical Billing for your practice.