AI Solutions for Healthcare

Let’s Talk Physical Therapy Emerging Trends

Codoxo recently discovered alarming emerging trends in physical therapy treatment that health plans and agencies should keep top of mind. Some of these trends are specific to laser therapy and cold or warm superficial or deep tissue therapy, which are being advertised and promoted by numerous physical therapy practice websites in multiple states.

What you Should Know:

  • Some of the services billed may not be within the scope of practice for a physical therapist.
  • The 969XX codes below are not typically listed in a physical therapist fee schedule because they are dermatologic codes. Additionally, 969XX codes are appropriately found in a physician’s fee schedule which would pay considerably more. 

Examples of codes to evaluate if submitted by a Physical Therapist:

  • 96910: Photochemotherapy; tar and ultraviolet B or petroleum and ultraviolet B 277)
  • 96920: Laser treatment for inflammatory (psoriasis) skin condition, total area less than 20 sq. cm
  • S8948: Application of modality (requiring constant attendance) to 1 or more areas; low-level laser, each 15 minutes (not covered by CMS) 

One exception would be HCPCS code G0283, which is for electrical stimulation. Your health plan’s policies may include additional exceptions for codes and services performed by a Physical Therapist.   

How to identify these unlikely services:

The Codoxo Forensic AI Platform and the query toolkit can assist your plan with identifying potential issues and with assessing these unusual physical therapy trends in your network.   

The following query criteria will allow you to surface services outside of the expected code range for physical therapy:   

  • Query = Professional, Aggregates, Rendering, Procedure Code  
  • Specialty = Physical Therapy 
  • Procedure code = Not Within This Range = 97010 to 97799 
  • Provider Payment Received = Minimum $1 

When the query aggregate results return, build a chart to identify the total payments for unlikely services using the following steps:   

  • Click Show Chart 
  • Variable 1 = Procedure Code 
  • Variable 2 = Provider Payment Received 
  • Chart Type = Sum 
  • Click Plot Chart 

Staying ahead of potential fraud, waste or abuse can be challenging without the right tools and resources in place. Advanced AI technologies can help support your team in detecting and preventing fraud before it impacts your bottom line.  

Reference Materials:
  1. L34049 Outpatient Physical and Occupational Therapy Services

    https://www.cms.gov/medicare-coverage database/view/lcd.aspx?LCDId=34049&ver=29&Date=&DocID=L34049&bc=hAAAAAgAAAAA& 

If you are interested in learning more about Codoxo’s forensic AI platform or would like to speak to Codoxo team member, contact us via info@codoxo.com.

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