New Evaluation Codes Officially Released by the AMA

September 26, 2016
Rick Gawenda

On September 6, 2016, the American Medical Association (AMA) released the 2017 CPT codes used by providers to bill insurance carriers for services rendered, including outpatient physical, occupational and speech therapy services. For physical and occupational therapy, there are significant changes regarding their current evaluation and reevaluation codes. Effective, January 1, 2017, 97001 (Physical therapy evaluation), 97002 (Physical therapy reevaluation), 97003 (Occupational therapy evaluation) and 97004 (Occupational therapy reevaluation) are being deleted and are being replaced with 3 new evaluation CPT codes per discipline and 1 new reevaluation CPT code per discipline.

In this article, I will provide the following information:

  • The new evaluation and reevaluation codes for physical and occupational therapy
  • A description of each code
  • A guidance on the amount of time that would be spent performing each level of evaluation
  • The 4 components associated with each evaluation that must be documented in the medical record in order to report the selected level of evaluation
  • What insurance carriers will use the new evaluation and reevaluation codes
  • Who would not be mandated to use the new evaluation and reevaluation codes

Physical therapy evaluations include the following components:

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  1. Question on billing 97750. If you complete testing and bill 97750 for the testing AND test results change your current POC (ie. Goals are re-adjusted). I assume you need to create a new POC. If nothing changes on the POC you just document your findings in a written format. Is this correct?

    1. We will not know for sure for Medicare until CI Version 23.0 is released and this version covers January 1, 2017 – March 31, 2017. My opinion is yes since currently, CMS pays for treatment on the same day an evaluation is billed.

  2. Is it safe to say that Functional Outcome measures (such as DASH, LEFS, Oswestry, etc) will now be required for all patients under HIPAA entities at evaluations/re-evaluations when using these codes?

    1. The new evaluation codes do not mandate that you must use a functional outcome tool and/or test.

  3. To help support the different levels of complexity, do you recommend using multiple ICD-10 diagnosis codes of other co-morbidities?

    1. It is a yes and no answer. Nothing states the ICD-10 codes for co-morbidities have to be on the claim form, but the co-morbidities should be listed in the evaluation and a statement as to why you think that co-morbidity will impact the plan of care.

  4. Thank you for this article. Have there been any definitions published regarding clinical presentation of “stable”, “evolving”, and “unstable”? And does the clinical presentation describe the therapy presentation only? or must it also include the medical presentation?