Today is the end of the first month of 2017 and the first month of physical and occupational therapists using their respective new evaluation codes. In a previous article released earlier this month, I discussed clinical presentation and provided examples of stable and uncomplicated characteristics, evolving clinical presentation with changing characteristics, and unstable and unpredictable characteristics. As always, the documentation of the therapist would support the clinical presentation they are reporting for that patient.
This week, I want to discuss elements, what is an element and how to count elements as they pertain to the physical therapy evaluations. Next week, I will discuss performance deficits, what are performance deficits and how to count performance deficits as they pertain to the occupational therapy evaluations.
Physical therapy evaluations include the following components:
- Clinical decision making
- Development of plan of care
Lets now define the examination component for the 3 physical therapy evaluation codes.
97161 – Physical therapy evaluation: low complexity: 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.
97162 – Physical therapy evaluation: moderate complexity: An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following body structures and functions, activity limitations, and/or participation restrictions.
97163 – Physical therapy evaluation: high complexity: An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.
To illustrate what is an element and how to count elements, I will use a 45 year-old right hand dominant female who tore her right rotator cuff 6 weeks when she stumbled going down the stairs and grabbed the handrail to stop herself from falling. Patient had the tear surgically repaired and is now presenting for her physical therapy evaluation. Patient resides at home with her husband and 17 year-old daughter. The evaluation includes the subjective intake, objective examination using standardized tests and measures as well as the completion of the Disability of the Arm, Shoulder and Hand (DASH) questionnaire.
To follow along with identifying and counting elements,
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“When a new referral for a different problem is received on an outpatient in a current plan of care, does the therapist have to complete a new initial evaluation or would a re-evaluation suffice. Does the therapist have to discharge the patient from the original plan of care before addressing the new referral or can the treatment approach be modified and blended together?
In my OPINION, a new condition/diagnosis unrelated to the current treating condition would be an evaluation since you can’t reevaluate something that you never evaluated. You would combine both plan of cares into one and treat the conditions at the same time.