General Surgery Coding Alert

Question: Can a stress test and a new physical therapy office visit be billed together?

AAPC Forum Participant

Answer: Yes, a stress test and a new physical therapy office visit can be billed together. However, it’s important to note that they are coded separately. For the stress test, you will choose from one of the following CPT^® codes:

• 93015 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report)
• 93016 (… supervision only, without interpretation and report)
• 93017 (… tracing only, without interpretation and report)
• 93018 (… interpretation and report only)

For the physical therapy portion, you will choose from the following codes:

• 97161 (Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family)
• 97162 (Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family)
• 97163 (Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family)

Always be sure to follow the visit notes from your practitioner to choose the most appropriate code(s) for the claim; but yes, they can certainly be billed at the same time.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC