French poetry and comic-book lore have taught us that “with great power comes great responsibility.” And with the imminent rollout of of new CPT codes for therapy evaluations and re-evaluations, rehab therapists would be wise to take that message to heart. That’s because, on January 1, 2017, PTs and OTs will have even more power in the way of accurately representing the patients they treat and the services they provide. Case in point: they’ll scrap all four existing evaluative codes—97001, 97002, 97003, and 97004—and adopt a set of new eight codes. And with this change, PTs and OTs also must determine—and code for—the correct level of complexity associated with each patient evaluation.

Now, it would be easy to bug out over this news, particularly as the holidays draw closer. But, as a PT or OT, you already know how to play detective during the patient’s initial evaluation. After all, you have to account for the whole picture—including any concurrent or past conditions that may impact the patient’s plan of care—in order to determine the best possible route of treatment. But with the adoption of these new evaluative codes, now it’s about applying that decision-making prowess in another way: to select the most accurate level of complexity for each evaluative episode. To that end, here are two examples that illustrate how to accurately code for the correct level of evaluation complexity. (If you haven’t already done so, I highly recommend reading this blog post before you dig into these examples, as it will provide context around the defining characteristics of each level of complexity.)

PT Billing Secrets: 5 Things Payers Don’t Want You to Know - Regular BannerPT Billing Secrets: 5 Things Payers Don’t Want You to Know - Small Banner

Determining the Right Level of Code Complexity

Patient Example 1

During the past two weeks, Steven has experienced some lower back pain, causing him occasional discomfort. But his condition has steadily worsened: within the past few days, the 53-year-old has been unable to go on his daily two-mile jog, as the lower back pain began spreading to the top and sole of his right foot. Unfortunately, Steven’s pain level—he rates it as a “six” on a ten-point scale—from the combined pain points has caused him to wake up between three and four times per night; it’s also caused him to feel restless each morning before heading to work. After performing several tests on Steven’s lower back and extremities, you conclude that he has decreased sensation to light touch and pin-pricking on the top and bottom of his right foot. With a 44% Oswestry score, Steven cannot sit or stand for more than 30 minutes at a time, nor can he lift any heavy weights.

Based on your evaluation of Steven, which level of evaluative complexity should you—the PT—select? The table below spells out all the details. 

Duration

You spend a half hour face-to-face with Steven and/or his family.

History

Steven has a history of low back pain, but there are no personal factors or comorbidities that would impact his plan of care. (For an explanation of what constitutes a “personal factor,” check out this blog post.) This means the pain in Steven’s lower back likely resulted from one injury or accident—not from an underlying health issue.

Examination

You complete an examination of the areas in which Steven is experiencing pain—in this case, his lower back and extremities—using standardized tests and measures that address:

  • One body structure (e.g., lumbar vertebral column)
  • Two body functions (e.g., muscle power and sensation and pain)
  • One activity limitation (e.g., mobility: walking, carrying, and sleeping)

(To learn more about the terms listed above, refer to the Vocabulary section of this blog post.)

Clinical Presentation

The clinical presentation is stable and/or uncomplicated.

Decision-Making

In your evaluation of Steven, you exercise clinical decision-making of low complexity using standardized patient assessment instruments and/or measurable assessments of Steven’s functional outcomes.

Correct Code: 97161 (Low-Complexity PT Evaluation)

Even though Steven has a history of low back pain, he doesn’t present with any personal factors or comorbidities that would impact his plan of care. Through your assessment, you also conclude that Steven’s condition doesn’t vastly restrict his everyday performance and activity levels. With these factors in mind, you conclude—at least at this stage—that it makes sense to code for low complexity.

Patient Example 2

Rhonda, who had a stroke nine weeks ago, spent 12 days in an inpatient rehab facility before receiving treatment for the past five weeks in a skilled nursing facility. The 82-year-old, who is now under your care, lost her husband five months ago and is having a hard time coping; she previously was going to a support group, but now is unable to attend. Nowadays, Rhonda is staying with her 53-year-old daughter, who provides routine care and assistance. Rhonda, who’s legally blind and has type 1 insulin-dependent diabetes, had a knee replacement a year ago and is presenting with short-term memory deficits as well as decreased ability to complete tasks. She’s also presenting with muscle weakness, a hemiplegic gait pattern, and proprioceptive deficits on her right side. Due to increased physical and cognitive deficits, Rhonda can no longer perform household chores like vacuuming, dusting, and doing laundry. These restrictions have forced you, the OT, to provide assistance and modify some of her evaluation activities during visitation.

Based on your evaluation of Rhonda, which level of evaluative complexity should you—the OT—select? The table below breaks it all down . 

Duration

You spend 45 minutes face-to-face with Rhonda and/or her family.

History

To establish Rhonda’s plan of care, you conduct an expanded review of her medical and/or therapy records. Through that review, you find that she recently received care at an inpatient rehab facility, a skilled nursing facility, a psychologist’s office, and a social work office. Additionally, as noted above, Rhonda is legally blind and has decreased mobility—both of which result in a limited current functional performance.

Examination

You complete an examination of the areas in which Rhonda is experiencing pain using standardized tests and measures that address:

  • Seven performance deficits (e.g., dressing, bathing, toileting, walking, getting in and out of bed, getting transferred from one location to another, and performing everyday activities.)

Decision-Making

In your evaluation of Rhonda, you exercise clinical decision-making of a moderate complexity using standardized patient assessment instruments and/or measurable assessments of Rhonda’s functional outcomes.

Correct Code: 97166 (Moderate-Complexity OT Evaluation)

Because Rhonda has such an extended history of physical, cognitive, and psychosocial issues that relate to—and impact—her current functional performance, you must conduct an expanded review of her records (i.e., one that is much more intensive than a patient with a brief medical history). Furthermore, after completing Rhonda’s OT assessment, you conclude she has seven performance-related deficits that hinder her ability to complete everyday activities and household tasks. However, even though the number of performance deficits exceeds the number included in the code description for a moderate-complexity evaluation, Rhonda’s case—as a whole—is not complex enough to warrant a high-complexity evaluation (remember, when there are elements of different levels of complexity in any given evaluation, you typically should code down). Thus, it makes sense to code for moderate complexity.


The holidays are fast approaching—and adding another level of complexity (pun intended) to therapists’ coding and billing game will no-doubt put some PTs’ and OTs’ tinsel in a tussle. But while the benefits of “great power” and “great responsibility” may not be immediately apparent, the long-term payoff is that therapists will eventually be able to create clearer snapshots of the patients they treat and the care they provide—which could have a positive effect on future reimbursement rates.

Finally, keep in mind that the examples above are just that—examples. Like snowflakes, no two patients are exactly alike—and there’s no one-size-fits-all template for selecting the correct level of complexity for any given evaluation. It’s up to you, as a PT or OT, to wield your clinical judgment and expertise to figure out which complexity category each patient falls into—which means you must be diligent about collecting as much relevant information as possible to help inform that decision. For a more in-depth explanation of how to apply the complexity criteria to every patient you see, be sure to register for our next live—and totally free—webinar, “New Year, New Codes,” which takes place on Thursday, December 15, 2016. During this 90-minute presentation, WebPT’s own Heidi Jannenga will team up with compliance guru Rick Gawenda to offer a comprehensive overview of the new CPT codes and how to use them appropriately.

Download your evaluation complexity quick guide.

Enter your email address below, and we’ll send you a super-simple chart to help you decide which level of complexity—and thus, which CPT code—is appropriate for any given patient evaluation.

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