How to Bill Revenue Code 0424 in 2025 (Avoid Denials)

In 2025, revenue code 0424 remains the standardized UB-04 code for “Physical Therapy – Evaluation or Re-evaluation,” critical for accurate home health and outpatient billing. ^{CMS Blue Button 2.0 Rev Code List}

Medical billing expert reviewing revenue code 0424 documentation for physical therapy claims

What Is Revenue Code 0424?

Revenue code 0424 designates charges for a physical therapy evaluation or re-evaluation on the CMS-1450 (UB-04) claim form. ^{Noridian Medicare: Revenue Codes} It applies whenever a qualified therapist assesses baseline function, sets treatment goals, or reviews progress. ^{CMS Functional Reporting FAQs}

CMS 2025 Updates

Manual & NUBC Confirmation

The National Uniform Billing Committee (NUBC) and CMS did not retire or redefine 0424 in the CY 2025 final rule. ^{Noridian Medicare: 0424 Definition}

PDGM & Payment Impacts

Under the Patient-Driven Groupings Model (PDGM), 0424 encounters inform functional scoring but do not change principal diagnosis grouping. ^{CMS Functional Reporting FAQs Q20–Q21} Providers should append modifiers (e.g., KX) for services beyond standard PDGM thresholds. ^{UHC Policy: Revenue Codes Requiring Procedure Codes}

Billing Guidelines

Procedure Code Linkage

Each revenue-code 0424 line must pair with a CPT code—typically 97161–97164 for PT evaluations—to avoid denials. ^{Excellus BCBS: Revenue Codes Requiring CPT}

Claim Form Placement

On the UB-04, enter 0424 in FL 42 (Revenue Code), the CPT in FL 44 (HCPCS/Rate), and charges in FL 46. ^{Noridian Medicare Guidance} Use Bill Types 032x/034x for home health and 011x–022x for inpatient/outpatient settings. ^{CMS Revenue Code List}

Payer-Specific Considerations

Medicare FFS

Medicare FFS accepts 0424 without local coverage restrictions if the service is skilled and medically necessary. ^{Noridian Medicare}

UnitedHealthcare

UHC’s “Revenue Codes Requiring Procedure Codes” policy lists 0424 as needing CPT linkage to process payment. ^{UHC Policy PDF} Their commercial plans often limit evaluation frequency to once every 30 days unless significant clinical change is documented.

Anthem Blue Cross

Anthem aligns with CMS definitions but enforces a 12-visit cap per benefit year for evaluations; confirm any pre-authorization requirements on payer portals. ^{Excellus BCBS Reference}

Documentation Best Practices

A compliant evaluation note must include baseline status, standardized assessment scores, and measurable functional goals. ^{AAPC CPT 97161 Guidance} Re-evaluations require justification of clinical change, progress metrics, and an updated treatment plan. ^{AAPC CPT 97164 Guidance}

Common Billing Errors & Solutions

Missing CPT Linkage: Omitting 97161–97164 causes automatic denials. ^{Excellus BCBS}
Wrong Bill Type: Using 021x instead of 032x/034x for home health denies the claim. ^{CMS Revenue Code List}
Exceeding Limits: Billing 0424 more often than payer policy allows flags audits. ^{UHC Policy}
Poor Documentation: Missing objective measures or goals risks medical necessity denials. ^{AAPC Guidance}

Frequently Asked Questions

Can I bill 0424 for telehealth PT evaluations?

Yes—Medicare FFS covers telehealth PT evaluations under Place of Service 02 if all documentation requirements are met. ^{CMS Telehealth Services}

Is a separate 0424 required within 30 days?

Only with significant clinical change; otherwise, continue with routine visit codes like 0421. ^{CMS FAQs}

Which modifier pairs with 0424?

Use KX for services beyond PDGM thresholds and –59 for distinct procedural circumstances. ^{UHC Policy}

Conclusion

Mastering revenue code 0424 in 2025 requires staying current with CMS/NUBC definitions, payer policies, and thorough documentation. ^{Noridian Medicare} This guide equips billing professionals to reduce denials, optimize reimbursement, and maintain compliance. ^{CMS Rev Code List}