🇺🇸United States

Lost revenue from incorrect use of timed vs. untimed CPT codes in SLP and rehab

2 verified sources

Definition

Many rehab providers misapply timed and untimed CPT rules, either billing timed codes only once regardless of length of session or failing to bill multiple units when time thresholds are met, which reduces legitimate reimbursement. Medicare and professional associations repeatedly publish clarifications because these errors are common and materially affect payment.

Key Findings

  • Financial Impact: $10,000–$50,000 per year per multi-discipline practice (conservative estimate where 5–10% of timed services are underbilled by 1–2 units).
  • Frequency: Daily
  • Root Cause: Misunderstanding that most SLP CPT codes are untimed and billed once per day, while many PT/OT codes are timed and should be billed in multiple units based on direct care time; confusion leads billers to undercount units or avoid multiple units to “stay safe.”[5][1]

Why This Matters

This pain point represents a significant opportunity for B2B solutions targeting Physical, Occupational and Speech Therapists.

Affected Stakeholders

Speech-language pathologists, Physical therapists, Occupational therapists, Billing staff, Practice managers

Deep Analysis (Premium)

Financial Impact

$10,000–$22,000 annually (WC claim denials and rework; delayed reimbursement; staff time managing separate compliance tracks) • $10,000–$25,000 annually (claim denials due to incorrect CPT unit formatting for WC; rework labor; partial rejections) • $10,000–$50,000 annual loss from timed code errors

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Current Workarounds

Call CMS or payer; ask ASHA hotline; reference printed NCCI tables; trial-and-error claim resubmissions • Call payer directly; check paper file with prior approvals; reference email thread with payer representative; submit claim with note and wait for response • Excel logs for session times cross-referenced with Medicare timed code rules

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Methodology & Sources

Data collected via OSINT from regulatory filings, industry audits, and verified case studies.

Evidence Sources:

Related Business Risks

Underbilling from mis-coded therapeutic activities vs. exercise in PT/OT

$5,000–$25,000 per year per mid-sized outpatient rehab clinic (estimate based on typical 10–20% differential in allowed amounts between 97110 and 97530 applied to hundreds of visits per month).

Denied or unpaid services from exceeding payer-specific therapy unit limits

$1,000–$10,000 per year per clinic, depending on how often sessions are delivered beyond allowed caps without approved extensions.

Delayed payment from incorrect or missing SLP and therapy modifiers

$50,000–$200,000 temporarily tied up in Accounts Receivable for a medium-sized practice when batches of claims are pended or denied until corrected and rebilled.

Clinical time lost to manual CPT code selection and rework

$20,000–$80,000 per year in lost clinical capacity per clinic (e.g., 15–30 minutes per clinician per day diverted from patient care to coding and rework).

Risk of recoupments and penalties from billing outside payer therapy coding policies

$10,000–$100,000 per audit cycle in recouped payments and non-payments for out-of-policy codes for a multi-location practice.

Suboptimal service mix and pricing decisions from poor visibility into CPT-level margins

$10,000–$50,000 per year in unrealized margin per clinic due to skewed case-mix and coding choices.

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