New Evaluation Codes and Percentages

In calendar year 2017, the Centers for Medicare and Medicaid Services (CMS) decided to pay the 3 physical therapy evaluation codes the exact same amount and the 3 occupational therapy evaluation codes the exact same amount. The Health Care Professional Advisory Committee (HCPAC) recommended different work relative value units (RVUs) and practice expense RVUs for the 6 new evaluation codes; however, CMS wrote they had concerns about having difficulty for them to evaluate the HCPAC’s recommended values or to predict with a high degree of certainty whether physical and occupational therapists will actually bill for these services at the same rate forecast by their respective specialty societies.

CMS wrote they had concerns that physical and occupational therapists would have difficulty reporting the appropriate complexity evaluation due to lack of familiarity and expertise in the differential coding of the new PT and OT evaluation codes that now include the typical face-to-face times and new required components that are not enumerated in the current codes. CMS also wrote they had concerns by pricing the codes differently, this may incentivize physical and occupational therapists to report the higher paying evaluation code when documentation in the medical record did not support that level of complexity.

So at what rate did the American Physical Therapy Association (APTA) and the American Occupational Therapy Association (AOTA) predict the 3 levels of evaluations would be billed at by physical and occupational therapists?

APTA predicted the following percentages for the 3 levels of evaluations: