The Codes Go Together

Rick Gawenda, PT has spent more than three decades decoding the rules the rest of the profession would rather not read. He's gone from treating patients in 1991 to one of PT's go-to voices on billing, coding, and compliance, the person owners call before they make a move. He's watched reimbursement pressure and audit fear keep clinics playing small, and he's just as clear about the opportunity most of them are walking past. We sat down to talk about RTM, audit risk, and why the codes only work when the data and human touch move together.

ben.barron: Before we get into it, how are mom and baby?

rick.gawenda: Doing well. Michelle has been living out there since the birth, so she finally comes home tonight.

ben.barron: How long ago was the delivery? What’s the baby’s name?

rick.gawenda: Maisey. Spelled M-A-I-S-E-Y, so everybody reads it as “Macy,” and they’d be right. The S sounds like a Z. We’ve already warned the kids her name will get misspelled her whole life. You correct people once and move on.

ben.barron: I can tell you’ve been thoroughly educated on how to say it. Congratulations again. Let’s get into it.

ben.barron: You flagged something before we started that I want to put right up top. The proposed rule.

rick.gawenda: Right. It’ll most likely come out June 30, July 1, or July 2, somewhere in there. So we’ll see if CMS proposes anything on the RTM front. Honestly, we don’t expect much. There are no new codes for 2027, and I don’t think there are any big RTM audits going on right now.

ben.barron: So we should publish this fast, before we have to change our minds on everything.

rick.gawenda: Pretty much.

rick.gawenda: One thing Alice Bell at APTA and I are working on is getting a Q&A into an upcoming issue of CPT Assistant. We want it to clarify that you only need one interactive communication in a calendar month. It doesn’t matter if you do 40, 50, or 60 minutes of management services. One communication, not one for every 20 minutes.

ben.barron: Is that the rule of the land already, or where you think it’s heading?

rick.gawenda: The way the code is written, with that stupid semicolon they put in there, people read it as one interactive communication for every 20 minutes.

ben.barron: And that communication has to be synchronous. Audio at minimum, an actual conversation.

rick.gawenda: At minimum audio, or audio plus face-to-face. But someone submitted the question to the AMA and got the answer back in writing. One interactive communication per calendar month, even if you bill 40 or 60 minutes. Even if you do a unit of 98980 and two units of 98981, still one communication.

rick.gawenda: We have it in writing, but we want it in CPT Assistant so it becomes public knowledge. That way, if a practice gets audited, or Blue Cross or Medicare says something, there’s something official from the AMA to point to.

ben.barron: What is CPT Assistant?

rick.gawenda: A monthly publication from the AMA that clarifies the intent and use of CPT codes.

ben.barron: So that’s straight from the horse’s mouth. Does CMS have latitude to disagree with how the AMA defines a code?

rick.gawenda: Here’s what every payer can do when a new CPT code comes out. They can decline to pay for it.

ben.barron: But that ship has already sailed on these codes.

rick.gawenda: Correct. So Alice and I have been going back and forth on email this week, and now we wait. It’s in the AMA’s court.

ben.barron: That’s really interesting.

ben.barron: Something else from that day stuck with me, and it wasn’t even about RTM. You talked about 98985 not being a checkbox. Not “I did it, I didn’t do it, I check a box, I bill it.” You were getting at something bigger. The codes are meant to go together. The data transmission plus the human interaction, the actual touchpoints with patients. Did I get that right?

rick.gawenda: Yeah. Whether it’s the 98985, the 2 to 15 days in a 30-day period, or the 98977, that part is a checkbox for the patient doing something. The intent, though, is the therapist or assistant logging in three or four times a week, checking the patient’s account, seeing how things are going, adding to the program, modifying it, answering questions. That’s the piece that justifies the skill of a therapist. Not the patient going check, check, check.

rick.gawenda: Some models in the market have treated RTM as simply checking a box that the patient completed the activity. That’s not the intent of RTM. It requires the combination of both.

ben.barron: That’s exactly what I’ve been pushing our team to articulate in the market. To me it’s the line between the two reasons to do RTM at all. One, it’s better care, and you get reimbursed for real work, the same way you should for anything you do with a patient. Two, if you’re only doing the data collection without the monitoring, the plan-of-care adjustments, the live interaction, you’ve missed the whole point. The point is using technology to fill the space between visits in a way that actually helps people get better faster.

rick.gawenda: Yep.

ben.barron: You also said you haven’t seen anyone audited specifically for RTM, but that it can create exposure inside a broader audit. Talk about that.

rick.gawenda: Say ABC Practice gets 20 charts requested, and they’re being looked at for therapeutic activity, 97530. As the Medicare contractor works through those 20 dates of service, if RTM happened to be billed during that same window, does everything become fair game? A lot of times the audit starts over something else entirely. A re-evaluation code, too many units of this, too many units of that, a patient seen for 32 visits and they want to know why. Once they’re in, everything’s fair game. But no, I haven’t had a single client get records pulled solely for RTM.

rick.gawenda: Now, do I think there’s a jump coming? Yeah. Once the 2026 data comes out, probably September 2027, I’d expect a big increase in billing, largely because of the 2 to 15 days piece. At some point the volume gets high enough that it’s worth a contractor’s time to look. We’re not billing 60 million units of RTM the way we are with therapeutic exercise and therapeutic activity. But it could get closer. And RPM is already on the radar.

ben.barron: It is? I haven’t followed that too closely. Just utilization climbing?

rick.gawenda: Utilization, and how long patients stay on it. With RPM you’ve got someone monitoring blood pressure or glucose, and I can see a physician keeping a patient on for seven, eight, nine months depending on severity. The interesting thing on the RTM side is the episode. If you’ve only got a patient on for two months, probably not an issue. But if you’re routinely running patients three, four, five months with high volume, that’s the kind of pattern that could get you looked at.

ben.barron: Got it. And because PT is episodic, six, eight, ten weeks with a real start and stop, the RTM window has a natural start and stop too. It doesn’t look like monitoring blood pressure for nine months. That analogy makes sense.

ben.barron: What about RTM as a way to stretch out discharge from a compliance standpoint? Here’s what I mean. New therapists, and honestly a lot of patients, struggle with the jump from two visits a week to nothing. I don’t love the word risk, Rick, but I don’t have a better one. Do you see risk in using RTM to extend the episode of care without the in-person visits happening at the same cadence? Any position statement or solid evidence out there?

rick.gawenda: There’s no position statement and no evidence. My opinion? Do I think the majority of RTM cases, and you can define majority as 50.1 percent or 80 percent, whatever number you want, end with the last in-person appointment? I do. As Ben comes in for his eight, nine, ten, twelve, fifteen visits, I’m updating his home program in person. If I’m doing RTM right, we’re engaged between visits. So by the last in-person visit, you’re pretty confident in the program, and you keep going.

rick.gawenda: Are there exceptions where you want to watch a patient another week or two or three, make sure they stay independent, make sure pain doesn’t return and limit function, maybe add a couple of things on RTM that don’t need to happen in person? Absolutely. I just don’t think that’s the majority. And I can’t tell you the exact percentage for any given practice.

ben.barron: And Medicare...

rick.gawenda: Technically Medicare doesn’t know when you discharge. The only signal is that you stop submitting claims with 97110, 97112, 97530, 97140. There’s no final claim with a special modifier that says “Ben’s all done.”

ben.barron: Right. Good callout. So from a data perspective, which is where Medicare starts, there’s no difference. If I go from 97110 and 97112 plus a little RTM, to just RTM for a stretch, Medicare can’t see why. Maybe a chart review tells a different story. But on the data alone, they don’t know whether Rick is out of the country for a month or just can’t get into the clinic, and we’re using RTM to keep his progress going.

rick.gawenda: Right. Say today is your last in-person visit, June 5. Two weeks later, June 19, maybe I bill a 98985 because I already hit the threshold for the month. June 30 I do a unit of 80 and a unit of 81, and you’re done. We never go into July. All of that happening inside June is probably not a big issue.

rick.gawenda: But if we finish you June 5 and I’m still billing RTM in July, then July 15, July 31, August 13, August 31, now that chart could get audited. And the question becomes, why did you have to keep Ben on RTM? That’s where the 80 and 81 matter. Ben checking off a 98985 isn’t the skill. Rick doing 80 and 81, modifying the program, that’s the skill.

ben.barron: This lines up with something we’ve started publishing. Working with our field CSMs, the people out with clients and frontline therapists every day doing the RTM work, we’ve kicked off a kind of MythBusters series. Here’s what people think about RTM, and here’s the reality.

ben.barron: You talk to people all day. What do you hear them get wrong? Where are they underselling RTM to themselves, on the business side or the patient side? Or what myths keep coming up?

rick.gawenda: I was giving a talk recently and asked how many people in the room were doing RTM. Out of more than a hundred, maybe eight or ten raised their hands. So why aren’t the rest? Part of it is they still don’t understand it. The bigger thing is they’re afraid of losing staff, because it’s more work, and there’s the what’s-in-it-for-me piece, the expectation of more pay or bonuses for doing their eight-to-five job. I had another reason, and it just left me.

ben.barron: I was in a 60-minute call with my boss earlier and I remembered and forgot the same important point three times. Got there eventually. So I’m right with you.

rick.gawenda: I was buying time while you kept thinking. Okay, here it is. It’s also the therapists and assistants treating the patients. They feel guilty about RTM, because now the patient has another co-insurance or co-pay. And I get it, but if it benefits the patient, and you educate them, and they decide they want it, that’s their choice. It’s no different than going to a restaurant where I can get chicken for $22, a filet for $42, or king crab legs for $67. What do I want?

ben.barron: Well said. So the barriers are: we can’t just pile something else onto a therapist who’s already maxed out. And some therapists are hesitant to sell RTM to patients because, as a profession, we’re terrible at talking about money and value.

ben.barron: I want to go back to your first point. People don’t know what RTM is. Specifically, what don’t they know? The codes? How it works? The patient benefit? Where are we on the understanding curve?

rick.gawenda: If I’m picking one, it’s how RTM works and what the benefit is. A lot of therapists and owners think of RTM as a silo. We do this, we get paid that. But RTM is about outcomes. It’s about patients being more engaged, attending more of their in-person visits, completing their plan of care. Better outcomes. Does that get you better Net Promoter Scores, the kind of data you can take to UHC, Aetna, and Cigna to renegotiate a poor-paying contract, because you can show you’re getting patients better, they’re not coming back with an exacerbation, and you’re reducing downstream cost?

rick.gawenda: That’s what I don’t think they understand, and they don’t know how to do it. To start collecting outcomes, you need the right tools: PROMIS measures, Net Promoter Scores, Google reviews. You have to put in the effort. And if you’re on social media or in some of these Facebook groups, the same complaints come up again and again: “We’ll drop the contract.” “Well, we can’t.” Yes, you can. Why not? “We’ll lose the patient.” Okay. At some point, you have to make a call.

rick.gawenda: The way we do therapy in 2026 is nothing like when I graduated in 1991. If you and I had opened a private practice then, it would look completely different from one we’d open in 2026.

ben.barron: I actually had this exact conversation earlier today with someone in healthcare, but not in PT. They were trying to convince me the biggest problem facing Physical Therapy is groups like Hinge and Sword, and that every practice out there wants more patients through the front door to build relationships.

ben.barron: I respectfully disagreed. That was the case when I owned my practice in the early 2000s, when we fought for every single referral, there were plenty of therapists to hire, and consumers didn’t yet understand the value of Physical Therapy.

ben.barron: We’re in a fundamentally different place now. Most practices, and this is a sweeping generalization, have enough patients. What we may not have is enough staff. So the Swords and Hinges of the world, good, bad, or indifferent, I don’t think it matters, because we can’t serve the whole market anyway. We don’t have the people. They’re not taking food off anyone’s plate.

ben.barron: PT can’t serve it all. We never have, and it shouldn’t be the goal, especially in the middle of a labor shortage. It’s a strange time to fight for more territory when you can’t serve the people already walking through your doors. Which, hopefully, is where RTM helps.

ben.barron: Maybe a last question. If you’re advising a clinic, and you’ve got a very different vantage point than I do, how should someone go understand RTM? They know it exists, they know Gawenda’s talking about it, they know they don’t know enough. What do they do?

rick.gawenda: If I’m being selfish, step one is a conversation with me, answering their questions. Then, do you want to talk to someone who’s doing RTM successfully? Let me put you in touch with a Susie or a Paul. Want to talk to someone from the company? Let me connect you. It depends on where they are and how much they already know versus don’t. But I get them talking to other people who are doing it. I’ll connect them with a trusted colleague at Limber Health.

ben.barron: So the social proof, talking to a fellow owner or operator who’s actually implemented it, isn’t a final box to check before picking a vendor. You’d pull it way forward, to the “why should I even be thinking about this” stage.

rick.gawenda: Oh yeah. One of the things I do for practices is what I call a practice analysis. We go through your income, expenses, the books, and run scenarios. Want to stay insurance-based? Want to go out of network? Here are your options. Have you thought about cash-based services, Pilates, yoga? Have you thought about RTM? “What’s RTM?” Okay, that’s a one-on-one conversation. “I’ve thought about it but I don’t quite get it.” Okay, that’s a two-on-one. Then I figure out where they are and go from there with the education, the training, or a referral.

ben.barron: Got it. Rick, this has been great. Give my best to Michelle, and congratulations again on the new grandbaby.

rick.gawenda: I’ll do that.

ben.barron: Talk soon.

Ben Barron | SVP @ Net Health | LinkedIn

Rick Gawenda | President & CEO @ Gawenda Seminars & Consulting | LinkedIn