Well here we are, six years into the great CPT code change of 2017 (as decreed by CMS and the AMA), which called for PTs to use a new set of evaluation and re-evaluation codes. Okay, that may have been a dramatic way to introduce that specific chapter in rehab therapy history, but with buzzwords like the Great Resignation, recession, and unprecedented times at play, I couldn’t help myself.
By now, the not-so-new CPT codes have worked themselves into every EMR, and the terms low, moderate, and high complexity are no less common to rehab therapists than the 8-Minute Rule or reimbursement cuts. But, that does not make them any less confusing—particularly for the new therapists entering the scene! To help, here’s a handy explainer on CPT codes for physical therapy evaluations.
PT Evaluation CPT Codes
Relegated to the windowless stacks library of the AMA, 97001 has been out of circulation for some time and replaced with a set of three different evaluative codes that are tiered according to patient complexity. Those codes are:
The APTA stated they hoped having three evaluation complexities would lead to improved payment reform from CMS, but six years in and there’s still no change. Presently, CMS maintains the work relative value unit (RVU) at 1.54 for all evaluation complexities, and re-evaluations are set at 0.96. In other words, CMS will reimburse the same amount for all three complexities—even if 97163 takes you more than 45 minutes to complete.
(For some background on how RVUs affect the dollar amount you see from Medicare reimbursements, check out this blog post created by our friend, Rick Gawenda. The APTA also has a downloadable calculator for you to check reimbursements by geography, as well.)
Levels of PT Evaluation Complexity
Now, the million-dollar question for any therapy professional is: how to classify the complexity of physical therapy evaluations? We’re glad you asked. To start, all the information needed will be collected in a thorough physical therapy evaluation. Here are the four main evaluation complexity factors collected in the PT evaluation, along with a few sub-factors:
Really quick, before we jump into the defining characteristics of each complexity level, let’s define a few terms that’ll pop up throughout this post:
- Body Regions: Refers to areas of the body, such as head, neck, back, lower extremities, upper extremities, and trunk.
- Body Systems: Includes the circulatory, skeletal, muscular, nervous, respiratory, immune, excretory, integumentary, lymphatic, cardiovascular, reproductive, and digestive systems.
- Body Structures: Refers to the body’s structural or anatomical parts (e.g., organs or limbs), which are classified according to body systems.
- Body Functions: Refers to physiological functions of body systems.
Now, let’s get into the nitty-gritty details associated with each level of evaluation complexity.
97161: Characteristics of a Low Complexity PT Evaluation
97162: Characteristics of a Moderate Complexity PT Evaluation
97163: Characteristics of a High Complexity PT Evaluation
PT Re-evaluation CPT Codes
While I’m on the topic of PT evaluation codes, I’d be remiss to not mention 97164—the PT re-evaluation CPT code that replaced 97002 back in 2017. Luckily, there is no need to tier complexity when coding for a PT re-evaluation. This code is simply defined as:
Hopefully this breakdown makes choosing the right level of complexity a little less, well, complex. Remember, clinical judgment plays a huge role in code selection, and your documentation should always clearly support your coding choices. That said, if you’re still scratching your head over the evaluation codes, leave us a question in the comment section below. We’ll do our best to track down an answer.
For more helpful billing FAQs, be sure to check out this blog post.