Hear ye, hear ye: We hereby declare that as of January 1, 2017, all PTs and OTs must begin using a new set of CPT codes to bill for therapy evaluations and re-evaluations. Actually, if we are being perfectly accurate, we’re not declaring anything; CMS and the AMA are—and we’re merely the messengers.

You might find it hard to believe, but with this CPT coding update, the evaluation and re-evaluation codes that PTs and OTs have come to know and love—97001, 97002, 97003, and 97004—are going away forever (well, presumably forever; we can’t predict the future). And in their place will come a brand new crop of evaluative codes unlike any that rehab therapists have ever used before. And bear in mind that this change applies to all HIPAA-covered entities and virtually all insurance carriers—not just Medicare.

Worried? Don’t be. In this post, we’ll break down everything you need to know about the new codes and how to use them appropriately. Sound good? Awesome—let’s get started.

Replacement CPT Codes for 97001

Physical therapists will no longer use the same evaluation code for every single patient. Instead, they will choose from a set of three different evaluative codes that are tiered according to complexity. Those codes are:

97161

Physical therapy evaluation: low complexity

97162

Physical therapy evaluation: moderate complexity

97163

Physical therapy evaluation: high complexity

Replacement CPT Codes for 97003

Occupational therapists also must select from a new set of three tiered codes when billing for patient evaluations. And like the new PT codes, these codes are organized by complexity:

97165

Occupational therapy evaluation: low complexity

97166

Occupational therapy evaluation: moderate complexity

97167

Occupational therapy evaluation: high complexity

Replacement CPT Codes for 97002 and 97004

This update also affects the codes for PT and OT re-evaluations. However, unlike the evaluation codes, the re-evaluation codes are not tiered according to complexity. Instead, there is one replacement code for 97002 and one for 97004, as shown below.

97164

Re-evaluation of physical therapy established plan of care requiring:

  1. An examination (including a review of history and use of standardized tests and measures)
  2. A revised plan of care (based on use of a standardized patient assessment instrument and/or measurable assessment of functional outcome)

97168

Re-evaluation of occupational therapy established plan of care requiring:

  1. An assessment of changes in patient functional or medical status, along with a revised plan of care
  2. An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals
  3. A revised plan of care (a formal re-evaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required)

Selecting the Right Level of Evaluation Complexity

Now, the million-dollar question for any therapy professional affected by these coding updates is: how does one go about selecting the appropriate level of complexity for each patient evaluation? We’re glad you asked. Here are the four main evaluation complexity factors, along with a few sub-factors:

  1. Patient history
    1. Personal factors
      1. Patient age
      2. Education level
      3. Coping style
      4. Social background
      5. Lifestyle
      6. Character
      7. Attitudes
    2. Comorbidities
      1. Past medical history (examples below)
        1. Obesity
        2. Diabetes
        3. Hearing loss
        4. Visual deficits
        5. Cognitive deficits
  2. Depth and results of examination and use of standardized tests and measures
    1. Expected progression
    2. Objective findings
  3. Clinical presentation
    1. Status of current condition
    2. Mechanism of current condition
  4. Clinical decision-making
    1. Goal establishment
    2. Prognosis and probable outcome

Vocabulary

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.

Characteristics of a Low-Complexity Evaluation

PT (97161)

Duration

Typically, the PT spends 20 minutes face-to-face with the patient and/or family.

History

The patient has a history of the present problem without any personal factors and/or comorbidities that impact the plan of care.

Examination

The PT completes an examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.

Clinical Presentation

The clinical presentation is stable and/or uncomplicated.

Decision-Making

The PT exercises clinical decision-making of low complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

OT (97165)

Duration

Typically, the OT spends 30 minutes face-to-face with the patient and/or family.

History

The patient’s occupational profile and medical and therapy history includes a brief history with review of medical and/or therapy records related to the presenting problem.

Examination

The OT completes an assessment(s) identifying 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.

Decision-Making

The OT exercises clinical decision-making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. The patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.

Characteristics of a Moderate-Complexity Evaluation

PT (97162)

Duration

Typically, the PT spends 30 minutes face-to-face with the patient and/or family.

History

The patient has a history of the present problem with a history of 1-2 personal factors and/or comorbidities that impact the plan of care.

Examination

The PT completes an examination of body systems using standardized tests and measures addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.

Clinical Presentation

The clinical presentation is evolving with changing characteristics.

Decision-Making

The PT exercises clinical decision-making of a moderate complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

OT (97166)

Duration

Typically, the OT spends 45 minutes face-to-face with the patient and/or family.

History

The patient’s occupational profile and medical and therapy history includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.

Examination

The OT completes an assessment(s) identifying 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.

Decision-Making

The OT exercises clinical decision-making of a moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. The patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable completion of evaluation component.

Characteristics of a High-Complexity Evaluation

PT (97163)

Duration

Typically, the PT spends 45 minutes face-to-face with the patient and/or family.

History

The patient has a history of the present problem with 3 or more personal factors and/or comorbidities that impact the plan of care.

Examination

The PT completes an examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.

Clinical Presentation

The clinical presentation is unstable with unpredictable characteristics.

Decision-Making

The PT exercises clinical decision-making of a high complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

OT (97167)

Duration

Typically, the OT spends 60 minutes face-to-face with the patient and/or family.

History

The patient’s occupational profile and medical and therapy history includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance.

Examination

The OT completes an assessment(s) identifying 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.

Decision-Making

The OT exercises clinical decision-making of a high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and

consideration of multiple treatment options. The patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable completion of evaluation component.


 

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 new 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 post.

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