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Common Questions from Our New PT and OT Evaluation Codes Webinar

Get the nitty-gritty details on the new PT and OT evaluation CPT codes. Click here to see answers to the most common questions, here.

Erica McDermott
5 min read
December 19, 2016
image representing common questions from our new pt and ot evaluation codes webinar
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This month’s webinar on the new CPT codes was our biggest one yet—more than 11,000 people registered to attend. With such a large—and clinically diverse—audience, we received a ton of questions. And due to time constraints, our hosts—WebPT’s own Heidi Jannenga and compliance expert Rick Gawenda—weren’t able to get to even a fraction of them during the live broadcast. Not to worry, though; we’ve done our best to answer them all here, in one giant FAQ article. Scroll through and check them out, or use the link bank below to skip to a particular section. And if you still have a burning question after reading through these, feel free to post it in the comments section; we’ll do our best to find you the answer. (Or, check out this recent PT billing FAQ.)

For those of you with questions about coding for pediatrics and hand therapy, we’re in the process of developing examples for both, so stay tuned to our blog—or subscribe here—for those.

What are the new codes for PT and OT evaluations?

When will these new codes go into effect? Who is impacted?

The eight new CPT codes (i.e., 97161-97168) replace codes 97001, 97002, 97003, and 97004. All HIPAA-covered entities are required to transition to these new CPT codes on January 1, 2017. That means Medicare and all private payers—except for workers compensation and automobile insurance companies—are required to make the switch. Please note that some non-HIPAA covered entities may choose to transition to the new codes voluntarily; thus, we recommend checking with all of your payers to determine how you should go about coding for evaluations in 2017.

Can you clarify the definition of “evolving” with respect to clinical presentation?

In this case, evolving simply means there are changing characteristics. For example, a patient who has been experiencing back pain for the past two weeks and whose symptoms have recently extended down his leg and to his foot would be considered to have an evolving clinical presentation.

Can you clarify the definitions of “stable,” “unstable,” and “unpredictable” with respect to clinical presentation?

In this case, stable indicates the patient’s condition hasn’t changed or has remained constant; unstable means the patient’s condition is volatile and inconsistent; and unpredictable can be defined as consistently fluctuating, with no assurances of what to expect.

Are stable, evolving, and changing clinical presentations relevant to accurately coding OT evaluations?

No. Those components apply only to PT evaluations. Remember, it’s important to consider PT and OT evaluations as two completely separate things. The coding criteria—and the vocabulary—differ greatly from one discipline to the other.

Are these time-based codes?

No. The new codes are not timed codes. Thus, you can only bill one unit of one evaluation code per evaluative episode, regardless of how long you spent providing the evaluation.

Are there any limitations as to the frequency with which these codes can be used?

As far as we know, there are no specific limitations in terms of when these codes can be used; you would simply continue to bill for evaluations and re-evaluations when appropriate based on the patient’s condition, his or her plan of care, and your state and payer requirements.

If the codes are not time-based, then why are there duration guidelines for each level of complexity?

The duration guidelines are just that: guidelines. These are meant as a starting point to help you classify the level of complexity. The key word in these guidelines is “typically” (e.g., for a low-complexity PT evaluation, “Typically, the PT spends 20 minutes face-to-face with the patient and/or family.”). Also, keep in mind that the time guidelines apply to evaluation services only; if you provide any treatment during the same visit, that time does not count toward the evaluation duration.

Do clinical decision-making and the level of evaluation mirror each other?

Not quite. Rehab therapists must take into account the patient’s history, examination, and clinical presentation when determining the correct level of code complexity. Each of these factors plays a role in therapists’ decision-making.

How will I know whether I have selected the right code? Will Medicare provide feedback?

As far as we know, Medicare will not provide feedback regarding code selection—at least not during 2017. However, it is important that you code to the best of your ability, as the data Medicare collects will be used to inform future payment structures and coding requirements.

What percentage of patients does CMS expect to fall into each complexity level?

According to this resource, “CMS cannot predict ‘with a high degree of certainty’ the utilization of the different levels of evaluation codes to maintain budget neutrality." In other words, CMS isn’t going into this phase with set expectations; it’s using the data it collects now to develop those expectations for the future.

What counts as a standardized test? Do I need to use an outcome measurement tool?

As Rick explained during the webinar, a standardized test can be something as simple as an MMT or ROM measurement. It doesn’t necessarily have to be an outcome measurement tool. That being said, Rick highly encourages providers to use OMTs when applicable.

I heard that there were going to be complexity levels for treatment codes, too. Is that still happening?

Originally, a tiered complexity system for treatment codes was set to go into effect one year after the tiered evaluation code system (i.e., January 1, 2018). However, implementation of the new treatment code system has been delayed indefinitely to allow for further data collection and analysis.

How do I apply the new evaluation codes?

What happens if I bill 97001, 97002, 97003, or 97004 after January 1, 2017?

In most cases, your claim will be denied.

If we have to create an addendum and re-bill a note after January 1, are we required to change the evaluation code, or can all dates of service before January 1 still be sent in with 97001, 97002, 97003, or 97004?

You should code based on the date of service, not the date of claim submission. So, all claims with dates of service prior to January 1, 2017, should include the old CPT codes.

What are the consequences of selecting a code that doesn’t accurately reflect the complexity of the the evaluation I provided?

In some cases, there may be no consequences for submitting an inaccurate code; or, depending on your billing history, it could trigger an audit. In any case, taking the time to select the code that best represents the evaluation complexity is incredibly important in the long run, as it will enable payers to better understand the work rehab therapists are doing and the types of patients they are treating. Ultimately, the data Medicare collects could inform future payment structures—and if rehab therapists fail to code accurately, those structures could be skewed to therapists’ disadvantage.

Can I bill for evaluation and treatment services on the same date of service?

This is partially dependent on the NCCI updates, but we anticipate that the current guidelines around billing for evaluation and treatment codes on the same date of service will not change significantly with the implementation of the new codes.

How do I code an evaluation for a patient with workers’ compensation as the primary insurance and Medicare as secondary?

First, you’d need to check with your workers’ compensation carrier to determine whether it is transitioning to the new evaluation and re-evaluation codes. If not—meaning it will continue to use the old evaluation and re-evaluation codes—then you would submit the old codes to workers’ comp. If, after workers’ compensation processes the claim, you’d like to submit to Medicare as the secondary, then you would need to switch any evaluation or re-evaluation codes you originally submitted to workers’ comp to the new evaluation and re-evaluation codes.

Do I code based on the complexity of the patient—or the complexity of the evaluation?

You should select the evaluation complexity code based solely on how the patient presents during the evaluation—using your own observations, as well as what the patient (and/or patient’s family) is telling you, as the foundation of your selection. If the patient’s condition changes during treatment, do not go back and change the original eval code. It serves as a one-time snapshot of the complexity of the evaluation—not the complexity of the patient. Please keep in mind that you may need to do a re-evaluation if the patient’s condition ends up changing to such a degree that you must adjust the plan of care. (To learn more about the criteria for billing a re-evaluation, check out this blog post.)

Do you always have to “code down” when a patient doesn’t meet the criteria for the next highest level of complexity in all areas?

Yes. For an evaluation to warrant a moderate or high complexity code, it must meet the criteria for those levels in all categories. Otherwise, you must code for a lower complexity evaluation.

When billing Medicare, should we still use therapy modifiers with the new evaluation codes?

You should continue to report “always therapy” modifiers (e.g., GP and GO for physical and occupational therapy, respectively) with the new evaluation and re-evaluation codes.

I practice in an acute care or SNF setting. How should I go about using these codes?

Skilled nursing facilities typically aren’t paid via CPT codes; rather, they receive reimbursement based on DRG/RUG levels. However, according to Rick, practitioners in SNF settings should still be familiar with these codes—especially if they are working in an inpatient acute setting. In some cases, patients who have exhausted their Part A benefits may need to use Part B benefits—at which time you would need to apply these new CPT codes for any evaluative episodes. Some patients also may transition from inpatient to outpatient status, in which case new evaluations would be charged under Part B with the new CPT codes.

Do I need to use the new evaluation codes for cash-pay patients?

Yes, you should still use your clinical judgment to select the appropriate code based on the level of complexity of the evaluation, and you should still document to support your coding decision. The patient may decide to seek reimbursement from his or her insurance company directly, and you should be prepared to present the appropriate information to facilitate this.

How would I code for an existing patient who comes in with a referral for a new diagnosis?

This depends on how you decide to treat the second diagnosis. If you plan to treat both diagnoses concurrently (i.e., during the same visits), then you would perform a re-evaluation and add the second diagnosis to the original case. If you decide to treat the second diagnosis separately (e.g., if the patient will be seeing a different therapist in your clinic for the second condition), then you would perform a new evaluation on the patient and code for the complexity of that specific evaluation. The complexity level of this evaluation may or may not be the same as the complexity level for the original evaluation. In any case, you cannot go back and change the complexity level of the original evaluation.

How do prior authorizations (PAs) factor into the rollout of these new evaluation and re-evaluation codes?

If you must submit an evaluation code to obtain the prior authorization before you provide the service, you may need to initially submit all three codes, as you would not know the complexity upfront. You would then receive payment for one of the three codes (whichever matches the complexity level of the evaluation you perform). We recommend contacting your payers to obtain further guidance.

Do most pediatric patients automatically fall into the low complexity category due to lack of past medical history?

No. Pediatric patients may have personal factors and/or comorbidities that may impact the plan of care, and those—along with the therapist’s objective examination findings and the patient’s clinical presentation—could end up warranting a moderate or high complexity code. This is why clinical judgment is so important to the code selection process. Logically, it wouldn’t make sense to automatically place a pediatric patient into the low complexity category based solely on the patient’s age (and thus, lack of past medical history). That’s why you must look at each patient individually and use your clinical judgment to apply the coding criteria appropriately.

How do I ensure my documentation supports my code selection?

What do I need to document to ensure the patient record supports my code selection?

We recommend adhering to the ICF guidelines for documentation. That means specifying the patient’s prior and current level of function as well as including a review of the body systems, structures, personal factors, performance deficits, cognitive function, and psychosocial skills. Truthfully, you should already be documenting to a high enough standard that you could justify the complexity of your evaluations. But with the potential for evaluation coding audits in the future, it’s now even more important for you to ensure your documentation would hold up to an auditor’s scrutiny. Ask yourself: Would an auditor would be able to identify all the criteria necessary to justify the level of complexity you chose?

How—and what—will I get paid when I bill the new codes?

Will all payers reimburse the same amount per code, regardless of complexity level?

Medicare will reimburse the same amount for all OT eval codes and all PT eval codes, regardless of the complexity level. (For more information on how Medicare will value the codes, check out this blog post.) This initial stage of the coding change is really about data collection so CMS can better understand the population receiving rehab therapy services. However, private payers may decide to reimburse differently based on complexity level (please contact your payers directly to obtain their fee schedules).

As side a note, Rick recommends that private practitioners set different price points for low, moderate, and high complexity evaluations within their clinic fee schedules, due to the differential cost associated with each. Also, while the current OT eval code pays more than the PT eval code, that will flip next year (the exact amount of reimbursement will depend on your geographic region).

Should we expect payment delays?

In most cases, no. However, some individuals have reported that the new codes aren’t on their payers’ 2017 fee schedules yet. In such cases, using the new codes could result in a delay, which is why we suggest checking with your payers directly before you submit any of the new evaluation codes.

When will the reimbursement levels change to a tiered structure based on complexity?

CMS has not announced plans for a tiered payment structure at this time; the agency is using this first stage to collect data that will inform future payment decisions. We will continue to keep you posted as we learn more. For a more in-depth discussion of the valuation of these codes, check out this blog post.

Will Medicare continue to pay for re-evaluations?

Yes, nothing has changed on this front. Medicare and most private insurance companies will continue to pay for re-evaluations. However, Medicare will not pay for progress notes, which are different than re-evaluations. To learn more, check out this post.

How much should I bill for these codes?

The amount you charge for each code will vary from payer to payer, but to learn more about how Medicare will value the codes, check out this blog post.

How will WebPT handle the new codes?

Will WebPT continue to have codes 97001–97004 available in the application?

Yes. WebPT will keep these codes in the system so you can use them to bill evaluations for any non-HIPAA covered entities that will not adopt the new codes.

Will WebPT be ready for the transition?

Absolutely. WebPT will have all of the new CPT codes available for use on January 1, 2017 (if you’re a WebPT Member, you can access screenshots of how the codes will appear within the application on this page). We also will provide extensive training videos in conjunction with the release of these new codes so you will understand how to use them within our system. The good news is that a lot of the language you’ll need to support your code selection is already built into the platform; now, it’s simply about making sure you are documenting those things as completely and accurately as possible. As a side note, you may need to update your fee schedule information for non-Medicare insurance companies.

Will WebPT change the evaluation and re-evaluation formats to account for the coding change?

Because there are no changes to the documentation requirements for patient evaluations—even with the introduction of the new codes—WebPT will not change the format of our evaluations and re-evaluations. If new documentation requirements are implemented in the future, we absolutely will update our application to account for those changes.

Will WebPT select the complexity level of a patient evaluation based on my documentation?

Clinical judgment plays a huge role in code selection. No two patients are exactly alike, and it’s important for providers to consider the whole picture as they make their code selections. Thus, there is no foolproof way to automate this process. For this reason, WebPT cannot auto-select the complexity level of any given evaluation.

Does WebPT offer SmartText functionality in the evaluation documentation fields?

Yes. SmartText functionality is available in the following sections:

  • Patient Education
  • Complaints/Gains
  • Functional Deficit/Gains
  • Patient Problems
  • Flowsheet

Will WebPT provide feedback as to how we are using the codes in my clinic/organization?

This functionality will be available in WebPT’s enhanced reporting module, which should be available to Members sometime next year. In the meantime, you may be able to collect this data using your Billing Report (with some spreadsheet manipulation).

Will therapists be required to include the appropriate code when completing their evaluations within WebPT?

Yes. The codes will show up in the billing section of the app, but the therapist will be responsible for selecting the correct complexity level of the evaluation.

How will the new codes affect things like modifiers, G-codes, and the therapy cap?

Can you use modifier 59 with the new codes?

The updated NCCI edit chart will be released in early January. At that point, we will know more about proper use of modifier 59 with respect to these new codes. However, as Rick pointed out, we anticipate that there will be new edit pairs containing the new codes themselves (for example, you will not be able to bill a low complexity PT evaluation with a moderate complexity PT evaluation).

How will the new CPT codes impact functional limitation reporting and G-codes?

Functional limitation reporting (FLR) is a requirement for Medicare Part B; however, some commercial insurances have also begun to require it. As a reminder, FLR is dictated by visit count, not necessarily visit type—and this CPT code update will not impact FLR. To learn more about FLR in general read our guide; to learn more about completing FLR if a patient self-discharges, click here.

Are the new codes subject to the therapy cap?

As of now, the therapy cap will remain in effect as we know it. (For 2017, the cap is $1,980 for occupational therapy services and $1,980 for physical therapy and speech-language therapy services combined.) However, as always, evaluations to determine whether therapy is medically necessary do not count toward the cap.

Regarding the updated Manual Medical Review process, is there a clear definition of targeted review? In other words, what would trigger a targeted review?

As part of the Final Rule, CMS extended the manual medical review process—which affects claims submitted above the $3,700 threshold—through December 31, 2017, albeit in a slightly different format. Next year, “not all claims exceeding the therapy thresholds are subject to a manual medical review process as they were before. Instead…[CMS is now] permitted to do a more targeted medical review on these claims using factors specified in section 1833(g)(5)(E)(ii) of the Act as amended by section 202(b) of the MACRA, including targeting those therapy providers with a high claims denial rate for therapy services or with aberrant billing practices compared to their peers.”

Will the complexity of the patient be inferred from the objective data, or will we have to justify this in the assessment?

As Rick and Heidi explained during the webinar, you don’t necessarily have to write a specific justification of your code selection. If you have documented thoroughly—especially with respect to the elements relevant to the evaluation complexity level—then your documentation should justify your decision without any additional explanation.

What’s the deal with PQRS and MIPS?

With PQRS no longer in effect as of January 1, 2017, will providers still be subject to the penalties assessed in 2017 and 2018?

Yes. If you, as an eligible provider, did not meet the requirements for satisfactory reporting in 2015 or 2016, you will still be subject to the 2% downward payment adjustment in 2017 or 2018, respectively.

Will WebPT no longer require me to complete PQRS measures in 2017?

No. Once the PQRS program is no longer in effect—as of January 1, 2017—WebPT will no longer require completion of those measures.

Can we continue to report PQRS to keep ourselves in the quality reporting groove and to better prepare for MIPS?

Beginning January 1, 2017, PQRS is no more. In its place is MIPS, although rehab therapists aren't eligible to participate until 2019 at the earliest. While CMS has indicated that there will be opportunities to report quality data on a voluntary basis, the agency has yet to distribute any formal guidelines about voluntary reporting. Learn more from this blog post.

Will MIPS reporting be built into the WebPT application?

WebPT will definitely have built-in MIPS functionality once this program becomes a requirement for PTs, OTs, and SLPs (currently, that’s set to happen in 2019). In the meantime, while CMS has indicated that it will allow non-eligible professionals—including rehab therapists—to participate in MIPS on a voluntary basis in 2017 and 2018, the agency still has not issued clear guidelines on how these professionals should go about submitting their data. We will continue to work with CMS to get more specific guidelines around voluntary participation.

Still have a burning question we didn’t cover in this post? Ask it in the comment section below. And if you haven’t already done so, be sure to subscribe to the WebPT Blog to make sure you always have the latest news and information about important changes like this one.


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