Effective January 1, 2017 Physical and Occupational Therapists will be using new complexity-based evaluation codes and a new re-evaluation code for each discipline. This policy change was discussed in the CY 2017 Medicare Physician Fee Schedule rulemaking. The goal is for therapy services across all care settings to have a uniform coding system. The Healthcare Common Procedure Coding System and Current Procedural Terminology, Fourth Edition (HCPCS/CPT-4) is the coding system used for the reporting of therapy services.
The current PT evaluation code 97001 will be deleted and replaced by three new evaluation codes and the PT re-evaluation code 97002 will be replaced by one new re-evaluation code. For OT, the evaluation code 97003 will be replaced with three new evaluation codes and re-evaluation code 97004 will be replaced with one new re-evaluation code.
The new PT codes are: 97161- Low Complexity Evaluation; 97162- Moderate Complexity Evaluation; 97163- High Complexity Evaluation; 97164- PT re-evaluation.
The new OT codes are: 97165- Low Complexity Evaluation; 97166- Moderate Complexity Evaluation; 97167- High Complexity Evaluation; 97168- OT re-evaluation
Each evaluation level has certain components and are different between PT and OT. PT has four components to each evaluation code and OT has three. The PT code components are: History, Personal Factors, and Comorbidities Impacting the plan of care; Examination of body systems; Clinical Presentation and Stability; and Clinical Decision Making and Development of the Plan of Care. Conversely, OTs three components are: Occupational Profile and Client History; Occupational Performance Assessments; and Clinical Decision Making and Development of the Plan of Care.
Each evaluation code for both PT and OT provides a typical amount of face to face time with the patient and/or family that is used as a guideline only. The typical time does not dictate the evaluation level but rather each component’s criteria being met drives the evaluation level.
A very short description of each PT and OT component criteria can be seen in the tables below.
PT Component Criteria Table
| 97161- Low Complexity Eval | 97162- Moderate Complexity Eval | 97163- High Complexity Eval |
| History: No personal factors and/or comorbidities | History: 1-2 personal factors and/or comorbidities | History: 3 or 4 personal factors and/or comorbidities |
| Examination: 1-2 body elements | Examination: 3 or more body elements | Examination: 4 or more body elements |
| Presentation: Stable | Presentation: Evolving with changing characteristics | Presentation: Unstable and unpredictable characteristics |
| Decision Making: Not complicated | Decision Making: Moderate complexity | Decision Making: High complexity |
OT Component Criteria Table
| 97165- Low Complexity Eva; | 97166- Moderate Complexity Eval | 97167- High Complexity Eval |
| Occupational Profile and Client History: Problem-focused | Occupational Profile and Client History: Detailed | Occupational Profile and Client History: Comprehensive |
| Assessments of Occupational Performance:1-3 deficits | Assessments of Occupational Performance:3-5 deficits | Assessments of Occupational Performance: 5 + deficits |
| Clinical Decision Making and POC Development: No Comorbidities; Limited number of treatment options considered | Clinical Decision Making and POC Development: May have a comorbidity affecting functional performance; Several treatment options considered | Clinical Decision Making and POC Development: 1 or more comorbidities affecting functional performance; Multiple treatment options considered |
The re-evaluation code for each discipline is a single code to reassess the resident if there was a change in the resident’s functional and/or medical status that requires a significant change in the plan of care. This isn’t a major change for therapists meaning the description is essentially the same but the CPT code itself is changing.
The new evaluation codes are a significant mindset change for physical and occupational therapists from what they are used to coding for an evaluation. Therapists have always assessed or considered all the areas included under each component of the new evaluation codes but now those areas will dictate the complexity level of the evaluation, which then in turn equates to a CPT code number and is justified in the therapy documentation.
Therapists and managers will participate in training in December to prepare for the January 1, 2017 change in evaluation codes. Happy New Year!
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