Choosing The Right CPT Codes: How To Stay Compliant And Audit-Ready With Daniel Hirsch

Choosing The Right CPT Codes: How To Stay Compliant And Audit-Ready With Daniel Hirsch

All right, ladies and gentlemen, here we are, the fourth episode of the compliance series. Fifteen minutes of action-packed compliance talk from our favorite compliance expert on the internet, Daniel Hirsch, with Risk and Compliance Analytics. The guy's a genius when it comes to compliance. In this episode, we're going to talk about something that I'm excited about because I don't know exactly what direction we're going to go with it, but I'm sure Daniel has an idea.

We're going to talk about CPT codes, the actual codes that you use to get paid. How do you use them? Which ones should we use? What's the issue? How do we make sure we're doing it right and maybe train our team on the right way to do that so that we can be compliant? Daniel, I'm going to toss it over to you. Tell us where do you want to kick this thing off at?

CPT Coding Risks & Compliance Basics 

All right. Thanks again, Adam. It's been a great few back-to-back weeks. It's been great topics. CPT codes, we're not going to go into the weeds because we'll be here literally all week if we're talking about how-tos to code, what exact codes. Also, they're constantly changing. We're going to talk about how to stay compliant and audit-ready. Really going to teach people the basics, and we're going to slam it into fifteen minutes, which is good.

CPT codes, though, when you think about it, it's really one of the least favorite parts of clinical practice. No one really went to school dreaming of "This is going to be one of my favorite things to do." It's one of the most risky areas of why people get audited, though. That's one of the biggest problems. It's not because of fraud or bad intent. It's really because of misunderstanding or maybe bad habits or outdated workflows. That's really what the problem is. We're going to put the pedal down, we're going to go full steam ahead and talk about how to choose correctly, accurately. What does audit-ready actually mean for how to stay compliant and really how to avoid mistakes?

We want people to understand how to avoid mistakes and how to really protect the practice without drowning therapists. I know you talked about this earlier with me. You don't want people to be overburdened. You don't want to drive people crazy and burn them out. You don't want to do that. There's a lot of technology out there to help with this in 2026, and it costs. You've got to be willing to pay for it. Absolutely, there's great technologies to help with CPT coding.

For clarity, you've got to know what does it represent? What do CPT codes represent? Last time, we talked about RTM and how that's really a clock control. You're managing the clock. CPT codes, they're not tasks. They're the representation of what your skilled services are. Auditors are not asking, "Did something happen or did it not happen?"

They're simply saying, "Tell the story." you're trying to tell the story of what was the skilled service that you provided, was it medically necessary, and was clinical judgment used? Those are the big three to say, "By the way, why do I need you, Adam, where I could just go down the street and go get a massage therapist or something like that?" It has to tell the story. From a CPT code, aka your billing becomes valuable.

Even if the treatment itself was you need to know, was it appropriate, was it medically necessary, that we said, was it skilled, and did your clinical judgment right, that's the theme that we're going to be revisiting constantly. It's rare for me to walk into a clinic and see poor treatment by therapists. That's really rare. I'll say probably twice that's ever happened to me.

The therapists fall into the trap of they're very friendly and they're very kind. They want to give away their time and energy and resources. We tell them not to. You have to be professional. I'll also go against the compliance doom and gloom that you hear from all the respected experts out there. I believe most therapists are probably underbilling, or they're simply not trained at a professional level to know how to ethically and accurately bill for their services.

That's what I think because you're not learning that at the DPT level. When you're coming out of school, that's not what they're trying to teach you. They're trying to teach you how to make decisions. We'll shift into areas of CPT coding. You have your time-based codes. Those are definitely your, hands-down, biggest risk. Your time-based codes, the most common problem is when people don't list the time properly, or maybe the minutes don't match the codes.

Sometimes they're lumping treatment together and they're not breaking that down. It's very hard to understand what's actually being provided or maybe it's not being recorded correctly. Total treatment time doesn't always equal billable time. The auditors are saying, "Okay, is there a start time? Is there an end time? What's the total minutes per CPT code?" They're just looking for the simple math. They're not looking for all that other wonderful stuff.

Again, I'm not going to talk about math with pts. I don't want to insult anybody. If you can quickly explain, the math is simply are you performing what you're claiming to perform and was it medically necessary? Does it actually match? Is it accurate? That's what you have to keep asking yourself. Also with modalities, we see this a lot.

When it comes to CPT code, there's a lot of confusion out there where people are billing, like heat or warm up on a bike, and I'm like, "Is that skilled?" You have to describe what you're doing. Don't just bill something for the sake of billing bike as something or neuro. You have to describe how it's medically necessary. Maybe are you educating your patient as they're on the bike? Are you reviewing the plan of care or their home exercise? Whatever you're doing, it has to always answer the same question. Is it medically necessary? Is it skilled?

Documentation Of Skill, Clinical Judgment, & Medical Necessity 

You're not looking, Adam, for just an activity list, because then you can go to the gym. If you just need an exercise list, go somewhere else. If you're looking for skilled decision-making, that's what the auditors are saying, "Yes, this should be reimbursed. Why? Because it's clinically appropriate." The worst is when you see an assessment that says, "The patient performed XYZ." I could care less, because I already know they did that. I already know the flowsheet says that or the activity log.

You've got to say what you're observing, what adjustments did you bring to the table. You're not selling yourself, but you really are describing why my brain was needed in this treatment. That's what you're trying to say, not just a list. People get that wrong all the time. Also, for over-documenting, that's one of the biggest areas that I beg people, please stop. If we want to know what took place and it's already there, don't rewrite it. Please.

Templates are good. That's another area where Medicare loves to give therapists a hard time. Medicare contractors are constantly saying, "You can't use templates. EMRs are making things too easy." the truth is identical language, visit after visit, that is a common problem. I give like the three-strike rule. If you're saying that nothing really changed in three visits, you should be worried.

You have to be showing progression, you have to be documenting that. Also, from the coding standpoint, the notes shouldn't just look the same. I'm not going to go into detail about a specific diagnosis or anything like that, but when you are looking at how you progress your average patient in a clinic, it should be a nice curve. It should be a nice graph that you could say, "We're making it more complex, we're using more valuable codes in that regard, we're making it more ING-friendly. We're doing activity-based stuff instead of just reps and sets."

We don't want to have cloned documentation. You definitely don't want that. Obviously, auditors are not trying to trick you. They're looking for consistency, and when it comes to how you're describing so I could tell you, I would get into a really bad habit of probably every 2 to 3 months, I will just be doing the same thing. Maybe I learned something, I took a course, i've seen this many times, where therapists get into the rut of "I'm just billing these four codes," and that's what your billing looks like for months until all of a sudden, you're like, "Maybe I should consider that 97535 or 537,” or something else. Maybe I forgot about the gait training code. Why not? Half our patients are lower extremity, maybe that's the appropriate thing to add.

Something to consider where you don't really want to get into the rut of doing the same thing over and over again to create a red flag for yourself. The gold of any note, though, when it comes to supporting the CPT codes, is by far the assessment. It's only a sentence. It's not hard to do, because no one could do that for you. AI's not doing it for you and that wonderful massage therapist down the street, they're not able to provide that.

Only your critical analysis in that one fantastic sentence on a note, that's what payers want to see. By the way, if you're ever stuck in an external audit or you're trying to argue and trying to prevent recoupment of funds or something like that, that will always win the day. You will always survive with fantastic assessments. It's not your activity list, it's not your really cool app you created. That's nice, but the assessment that one fantastic assessment that is really saying, "By the way, we needed Adam. We didn't need that other source down the street."

I talked about more words, over-documenting, the sets, the reps, all that nice objective data, that should live somewhere. If you're attaching that nicely into your note, that's fantastic, but you need to say why the intervention was skilled. The CPT code has to say, "Well, why was it skilled? What functional deficits did it address? Did my brain, did my clinical judgment did that apply to the service?"

Avoiding Overdocumentation & Cloned Notes 

I guess i'll also go out on a limb here. I don't like peer-to-peer. You probably have heard peer-to-peer reviews are part of an audit program for compliance. The truth is they often provide very little value to a practice. A lot of times, people hate doing it, and it's hard to convince people to give up lunch breaks. There's, again, so many affordable options that you could either outsource or bring in-house from a technology solution. I think that's one of the biggest things.

When you have your CPT codes, I know we talked about the time codes, they are all valued differently. You can't just tell your staff, "By the way, I need you to bill top three," because what happens every year? We get a fee schedule, and they're magically always recalibrated. Why does that happen? It's because everyone's playing the same game.

Everyone's using data, I would assume.

They're saying, "Well, why did 97530 get reduced in value,” because all of a sudden, magically, it's being used 50% more this past year because it went up last year, or, “Why is neuro more valuable versus therapeutic exercise?" I like to just simply say, always pick the code that accurately reflects what you're doing as opposed to just chasing a dollar sign. I heard a webinar from an EMR that put out saying they're surprised that people are using group code.

I'm like, "Really? Why are you surprised?" It's a fantastic code. It's not worth very much, but it's not timed. It's something where you could say, "My one minute was worth a few dollars,” but you could extrapolate that to say maybe that was three people sitting there for that one minute. It actually does become pretty valuable. If you document appropriately, it's one of these things where it's a great tool to have to diversify your CPT coding.

I say this all the time, don't just do the top four that everyone else is doing. Don't just keep doing the same exact thing. Don't be like me and every two months catch yourself and say, "I haven't billed gait training in four months. Why haven't I done that?" the answer is because is it reflective of the patient sitting in front of me and does my service actually match what I'm coding? We're not coders. We're not medical coders. We're not medical billers. We're therapists. We're trained therapists who are supposed to, again, be using the clinical judgment and the justification to support these CPT codes.

I had a lot of things that popped in and popped out of my head as I heard you talk, but the one thing that I held on to is you mentioned technology. There's a lot of AI tools now that are helping you formulate the sentence structure that creates that justification. I would assume that that tool, if it's any good, is going to help you have a better assessment.

I think the future, Adam, is going to be the "click here to validate." you can't be a creative writer. We don't want English majors. We want people to be able to simply say, "Yes, that is what I did and my license is going to sign off on that." Yes, that's what I think the future is, just to simply say, "You know what? I read that. That is what happened. Yes, I like that."

I would assume now the audit process have to be a little different because it's going to be harder to catch. It should be consistently decent across the board if AI's writing it.

I think that's where we're finally leveling the playing field. All these years, we are constantly saying, "Well, where did you go to school? Where was your clinical affiliation," and then you were magically supposed to be up to a certain level. We're leveling the playing field and saying everyone should be at least good. I think that's what it's trying to do, and I think personally, as an auditor, I could tell you I love that.

I think it's really great because there's so many other things you need to be worried about. There's so many other things you need to be focusing on. The patient in front of you, you're supposed to be worried about that and that progression and that management, not on how good was that sentence structure.

It's usually like you said. Most therapists are doing a really good job. They're just having a hard time putting it into words that make sense, that actually captures the depth of the skill. I'm guilty of it too. When you see 100 total knee patients over and over, you can normalize that experience so much that it feels like it's unskilled because they're coming in and doing quad sets.

Really, there's a neuromuscular facilitation of the quadriceps muscle to stabilize the patella, which is the truth, but we oversimplify what we're actually doing and sometimes we have a hard time articulating the value there and the skilled care. That's where I think AI really helps with that. Helps you continue to capture the skill.

It's available. Why not take the advantage? I don't understand why people are saying, "It's a tool." Yes, but we have a goniometer too. Why would I want to eyeball it when I could use a tool that does a great job?

Give me the single most important thing that a therapist should focus on to improve their documentation and justification around CPT codes. What's the one most important thing?

Accurate Time-Based Coding & Using AI Tools 

The number one thing for CPT coding is it's got to be if you're doing time minutes, the minutes have to add up. Be cognizant of if you need 8 minutes, do not bill 6. That ultrasound setting that for some reason is set to 6, change it to 8 because you're not going to get billed for it. If it's still clinically appropriate, be aware of what it is, because we don't want to just give away our time either. It doesn't make sense. Most of the companies that we work for are not pro bono. This is not just a nonprofit organization. We're there to do a job and we want to be compensated for our time.

The following episode is our last episode, 5 of 5, and I don't even remember what the topic is. We can leave it as a cliffhanger, but it's going to be good. Daniel, thank you for your time and we'll see you next time.

Thank you, Adam. All right, awesome.

Important Links

• Risk and Compliance Analytics
• Daniel Hirsch on LinkedIn
• Risk and Compliance Analytics on LinkedIn