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New Evaluation Codes for OT/PT and Complexity: What Do These Changes Mean?

Written by: Shawn Hewitt on Tuesday, November 8, 2016 Posted in: Outpatient Rehab

In early September 2016, the American Medical Association (AMA) announced important changes in regards to occupational and physical therapy evaluation and re-evaluation codes. Starting January 1, 2017, the CPT codes for occupational therapy evaluation (97003), occupational therapy re-evaluation (97004), physical therapy evaluation (97001), and physical therapy re-evaluation (97002) are all being replaced with three new evaluation codes and one new re-evaluation code. These changes are per discipline for OT and PT respectively.

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 problem
    • An assessment(s) that identifies one-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-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

    Simplify CPT Coding

    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 1-2 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-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

As you can see, there is a key focus on the complexity of the evaluation completed. Although CMS has proposed the same value of the codes for FY 2017, the changes will still require education for therapists to understand the differences and when to select the correct codes. Along with understanding the differences in complexity, it will be just as important to educate therapists on accurately documenting  low, med, and high complexity. CMS has stated that it will assess the use of the different complexity types and will make future “value determinations” based on that data.

We anticipate the final rule to be released in November, which will provide the final code descriptions and values that would be effective on January 1, 2017. Mediware strives to communicate industry and market information that is important to you so that staying compliant is easier to manage so you can stay focused of providing quality care to the patient.

This Post Has 18 Comments
  1. Great question. It really comes down to how/where your patient claims are being submitted. At this time it applies to any patient that falls under payment for Physician Fee Schedule/Medicare Part B. So on the surface this will mainly be in OP but, if any patient is going to be billed under Medicare Part B, the new codes will apply.

  2. Speaking from an IRF perspective, we are moving forward with the new CPT codes for our inpatients – even though <1% of our patients come in with Part B as their only coverage. The reason is that it is our understanding that the old eval CPTs (97001-97004) are being inactivated by AMA and the ONLY valid eval CPTs will be the new ones. So basically all OT/PT eval/reeval charges have to use the new CPTs regardless of the payer (with some exceptions like worker's comp, etc). We've received our 2017 CPT data files from AMA and 97001-97004 are not there.

    Not sure how others are treating it, but that is how we are proceeding.

    1. Scott, I am in agreement with your interpretation. AMA created these new codes in conjunction with several stakeholders including the APTA/OPTA/ and CMS. But the codes apply to nearly all patients, regardless of payor. The exceptions include Workman’s comp and auto insurance claims. As you stated, the old eval/reeval codes are going away.
      Even though services in a SNF/hospital/IRF are paid under PPS/DRG or some other type of capped payment, the providers still have to itemize services provided, and that is done with CPT codes.

    2. You are correct. I have another blog coming out this month that speaks to more of WHO needs to follow these new codes. The crux of it:
      So…When and where do OT’s and PT’s need to use the new codes?
      • All HIPPA entities are required to use the new CPT Codes. This includes the following:
      o Health insurance companies
      o HMOs, or health maintenance organizations
      o Employer-sponsored health plans
      o Government programs that pay for health care, like Medicare, Medicaid, and military and veterans’ health programs.
      • Entities that are not covered by the HIPPA 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.
      o Workers compensation
      o 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 there is, you can then start to break down where your OT’s and PT’s work from
      • Lines of Service:
      o OP:
       Hospital OP Departments
       Private Practice
       OP Rehabilitation Agencies
       CORF’s (Comprehensive Outpatient Rehabilitation Facilities)
      o Those Special Cases Where There is Medicare Part A BUT the Patients are Billed as Medicare Part B:
       Observation Patients: Those Medicare patients seen in a hospital as observation status. They are seen at the hospital setting and discharged to home
       ER: Those Medicare patients seen in the hospital ER and discharged to home
       SNF’s: When a skilled nursing 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.
      o Acute/IRF (FIM)/SNF (RUG): Typically in these settings, CPT codes are not required for the claim. The patient is billed based on the associated Prospective Payment System. Often times, CPT’s are collected to more clearly specify what was done and/or to assist with productivity measure. We recommend providers in the Inpatient space use the new CPT Evaluation and Reevaluation codes. The benefits would be to create a consistent training and understanding of billing services across your OT’s and PT’s that 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 coverage’s. Does everyone remember when Functional Limitation Reporting hit the scene and how to manage Observation patients? Same thing here with billing the “Evaluation” CPT’s. 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 in understanding WHO, WHEN, and WHERE the new Eval CPT’s are required to follow. For those of you that are MediLinks Clients, your organizations have all been contacted by the RSM’s and Content Team with the plan and steps to ensure successful compliance. For those of you that 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/

  3. Could you provide an example of the documentation requirements. I work in acute care and we are having difficulty defining the evaluation complexities in this setting and how this is documented.
    Thank you

    1. Denise, I’m glad you posed this question. We are having similar debates in my facility. We already have most of the requirements in our documentation, but just not always explicitly stated. Traditionally, we encourage staff to use the “Assessment” section of their eval to address what factors affected the plan of care and/or complexity of the eval. So, we now have created some changes (We use EPIC) that match the requirements word for word. For example, in our eval, we have a row that says “History/comorbidities that may affect plan of care” followed by a pick list of about 25 of the most common comorbidities we see. We have another row for “Personal Factors”. It’s up to the evaluating therapist to determine what could affect their plan of care and pick it from the list, or free text in something not on the list.

      The Examination section is pretty self explanatory and didn’t need any changes. In addition, we’ve long had a section within our Objective testing that included “Standardized Tests and Measures” – so its easy to document that requirement (i.e. if we do TUG or Short Berg Balance Test or Tinneti POMA).

      For “Presentation”, we simply created a row called “Patient Presentation” and gave the three choices. We also put in a row to free text any comments the evaluating therapist thought we relevant. Our big debate here was trying to determine what type of patients would fall into what categories. One difference from OP therapy is that in ACUTE care, the patient is not in the hospital FOR therapy. But they need it to help address issues related to their illness/surgery/etc. SO, the patient could have somewhat stable and uncomplicated presentation from a PT point of view, but be quite unstable medically (or vice versa). Which point of view are we supposed to determine this from?
      Another example would be a typical total joint replacement seen day of surgery. Some argued that the presentation usually with “stable and/or uncomplicated characteristics “. I argued that maybe they should be considered “evolving with changing characteristics” (Moderate Complexity criterion), even though we expect those patients to progress in a predictable way. Some seemed to interpret “evolving” only in a negative way (the condition is worsening). We didn’t really come to any solid conclusions on that.
      Finally, we made a “Decision making” row and again, simply put the three criteria choices as listed in the codes for Low/Moderate/High complexity. What is unclear to me is if the typical goals written in an Acute care setting, which are very functionally based, are sufficient to meet the standard of “measureable assessment of functional outcome”.
      We have made efforts to include more tests and measures in our acute care documentation but only when its clinically relevant. We don’t do any systematic tracking of progress. I am aware of the “AMPAC 6 clicks” instrument but it is proprietary and most other tools are extensive and cumbersome. Usually “min/mod/max assist” is enough for me to
      communicate status and set goals that help me make recommendations for the next level of care (i.e. home with home health PT vs. SNF or IP Rehab). The score of a test may help me make that choice but I hardly believe its a critical component to my decision making when evaluating every patient.

  4. Few questions: First when discussing the occupational profile do you just list current functional status for self care, work, mobility, etc or do you complete something like the DASH or UE index to get a score? Second, when looking at modifications to complete evaluation to determine complexity, do you list what modifications you used or do you just identify that the evaluation required min, mod, significant modifications to complete. Thanks.

    1. My goal was to communicate the info about the new codes. Your actual documentation practices should be based on your facility approved process. Now with that I said, when discussing occupational profile both may be appropriate based on your course of treatment. If you are assessing and your findings have a current functional status that describes the occupational profile, and your documentation supports that, you should be good. I think any additional assessment or documentation like the DASH only supports those findings to describe the occupational profile.

      For your second question, it is probably good practice to describe as much as you can about any modifications that paint the picture or describe. Using terms like min/mod may mean different things to different people. If you use a term like minimal modifications, I would then add additional description to how that changed or impacted the task or activity.

  5. I work in pediatrics (0-17yo), where I’ve used “standardized tests” when mandated by the payer (mostly early intervention). These standardized tests include the Peabody, AIMS, BOT-2, just to name a few. With the new codes, are these standardized tests mandated to be used in evaluations?

    1. The language on what type of standardize test is open so that the clinician must base their decision on use of tests and measures. Documentation should reflect what tests and measures were used to validate ” examination of body systems using standardized tests and measures. We have not seen any specific list of mandated tests. Again, it is important that documentation reflect any test you use.

  6. Can someone please give me a concrete resource stating that some payers are not required to follow the new codes (i.e. work comp)? Our EMR and billing team completely erased the old codes from our system, and are insisting that ALL payers are required to use them. I have showed them that other EMR are not doing that, but they are refusing to put the old codes back in. I need a good resource that I can cite. I have been searching on the CMS website with no luck.

  7. Do you anticipate any scenarios where the complexity of a PT evaluation would vary from the complexity of an OT evaluation? For example, the OT scored the eval as low complexity and the PT as high based on each discipline’s involvement.

  8. When billing Medicare with the new codes are we required to still use modifier “59” if there are other charges for the same date?

    1. Terri
      To our understanding if you are performing treatment on same day as eval, you can still use the 59 modifier if your treatment charges warrant a CCI Edit.

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