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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.