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New Eval Codes for OT/PT Jan. 1, 2017: Who Needs to Follow Them?

Written by: Shawn Hewitt on Wednesday, December 21, 2016 Posted in: Acute Care Rehab, Inpatient Rehab, Outpatient Rehab

We have been blogging and communicating with our current clients about what should be done regarding the new eval codes for OT/PT starting Jan. 1, 2017. There are still many questions about who needs to use the new evaluation CPT codes.

Q&A

So… When and where do OTs and PTs need to use the new codes?

-All HIPPA entities are required to use the new CPT codes. This includes the following:

  • Health insurance companies
  • HMOs, or health maintenance organizations
  • Employer-sponsored health plans
  • Government programs that pay for healthcare, like Medicare, Medicaid, and military and veterans’ health programs

-Entities that are not covered by the HIPAA rules include the following (unless they fall into one of the above entities). These entities can continue to use the “old” codes if they want, or they may accept the new codes. It is recommended to contact the workers comp and no-fault auto plans you work with to see where they fall.

  • Workers compensation
  • Auto no-fault carriers

Are these codes just for OP or are they for acute, IRF, and SNF as well?

-Once you identify what type of HIPAA entity you are and/or what type of payer you are working with, you can then start to break down where your OTs and PTs work from

-Lines of Service:

  • OP
  • Hospital OP Departments
  • Private Practice
  • OP Rehabilitation Agencies
  • CORFs (Comprehensive Outpatient Rehabilitation Facilities)

-Those special cases where there is Medicare Part A BUT patients are billed as Medicare Part B

  • Observation Patients:  Those Medicare patients seen in a hospital under observation status and discharged to home
  • ER:  Those Medicare patients seen in the hospital ER and discharged to home
  • SNFs:  When a skilled nursing facility provides therapy services billed under Part B
  • Inpatient:  Those Medicare patients where Part A coverage exists (or not) BUT for specific reasons when the patient is billed under their Part B benefit

-Acute/IRF (FIM)/SNF (RUG)
Typically in these settings, CPT codes are not required for claims. Patients are billed based on the associated prospective payment system. Oftentimes, CPTs are collected to more clearly specify what was done and/or to assist with productivity measures. We recommend providers in the inpatient space use the new CPT evaluation and re-evaluation codes. The benefits would be to create consistent training and understanding of billing services across your OTs and PTs who may have exposure to multiple lines of service. It is also helpful to be using the same language when those special cases (listed above) occur between Medicare Part A and Part B coverages. Does everyone remember when functional limitation reporting hit the scene and how to manage observation patients?  Same thing here with billing the “evaluation” CPTs. If you are using the same language from the start, then you are covered when those special cases happen.

We hope this helps to clarify some of the fuzzy areas and helps you understand WHO, WHEN, and WHERE the new eval CPTs are required. For those of you who are MediLinks clients, your organizations have all been contacted by the RSMs and content team with the plan and the steps necessary to ensure successful compliance.

To recap: Starting with services on Jan. 1, 2017, OT and PT will be required to use the new evaluation CPT codes. These codes specify a level of complexity based on components of the medical and therapy history, an examination of performance deficits as well as body structures and functions, activity limitations and/or participation restrictions, clinical decision making/clinical presentation, and typical time spent face to face with the patient and/or family. The NEW evaluation CPT codes will replace occupational therapy evaluation (97003), occupational therapy re-evaluation (97004), physical therapy evaluation (97001), and physical therapy re-evaluation (97002).

 

The NEW Occupational Therapy Codes

97165 – Occupational therapy evaluation, low complexity, requiring these components:

  • An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problemAn assessment(s) that identifies one to three performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions
  • 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. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (i.e., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component
  • Typically, 30 minutes are spent face to face with the patient and/or family

97166 – Occupational therapy evaluation, moderate complexity, requiring these components:

  • An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance
  • An assessment(s) that identifies three to five performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions
  • Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (i.e., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component
  • Typically, 45 minutes are spent face to face with the patient and/or family

97167 – Occupational therapy evaluation, high complexity, requiring these components:

  • An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance
  • An assessment(s) that identifies five or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions
  • Clinical decision making is of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (i.e., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.
  • Typically, 60 minutes are spent face to face with the patient and/or family

97168 – Re-evaluation of occupational therapy established plan of care, requiring these components:

  • An assessment of changes in patient functional or medical status with revised plan of care
  • An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals
  • 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
  • Typically, 30 minutes are spent face to face with the patient and/or family

The New Physical Therapy Codes

97161 – Physical therapy evaluation, low complexity, requiring these components:

  • A history with no personal factors and/or comorbidities that impact the plan of care
  • An examination of body system(s) using standardized tests and measures addressing one to two elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions
  • A clinical presentation with stable and/or uncomplicated characteristics
  • Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome
  • Typically, 20 minutes are spent face to face with the patient and/or family

97162 – Physical therapy evaluation, moderate complexity, requiring these components:

  • A history of present problem with one to two personal factors and/or comorbidities that impact the plan of care
  • An examination of body systems using standardized tests and measures in addressing a total of three or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions
  • An evolving clinical presentation with changing characteristics
  • Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome

-Typically, 30 minutes are spent face to face with the patient and/or family

97163 – Physical therapy evaluation, high complexity, requiring these components:

  • A history of present problem with three or more personal factors and/or comorbidities that impact the plan of care
  • An examination of body systems using standardized tests and measures addressing a total of four or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions
  • A clinical presentation with unstable and unpredictable characteristics
  • Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome
  • Typically, 45 minutes are spent face to face with the patient and/or family

97164 – Re-evaluation of physical therapy established plan of care, requiring these components:

  • An examination including a review of history and use of standardized tests and measures is required
  • Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome
  • Typically, 20 minutes are spent face to face with the patient and/or family

For those who are not MediLinks clients but are struggling with staying compliant or looking for partners/solutions to help keep you compliant, please check us out at https://www.mediware.com/rehabilitation/.

Check out these previous blogs for the NEW CPT Eval Codes:

What Do These Changes Mean?

The Year Isn’t Over Yet!