New PT Evaluation Codes & Clinical Presentation

January 9, 2017
Rick Gawenda

With the new physical therapy evaluation codes that began on January 1, 2017, I am receiving many questions on how to determine the appropriate complexity level to report on the claim form to the insurance carrier. Many of the questions relate to the clinical presentation of the patient and the following words:

  • CPT code 97161: Stable or uncomplicated characteristics
  • CPT Code 97162: Evolving clinical presentation with changing characteristics
  • CPT Code 97163: Unstable and unpredictable characteristics

In this article, I will provide some examples for each of the 3 levels of clinical presentation.

Stable or Uncomplicated Characteristics:

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  1. You said PQRS will no longer be required this year. But do we continue documenting/billing the functional G-Codes?

    1. Yes, functional limitation reporting (FLR) is still required in 2017. FLR and PQRS are 2 separate programs.

    1. The therapist would need to determine the level of complexity based on the 4 components and the supporting documentation in the medical record.

    1. The documentation in the medical record would support the level of complexity for the PT and OT evaluation codes billed.

  2. Rick, In the CPT Part2 Webinar you mentioned that the Eval Complexity was based on the four components and the lowest component of the four would determine the level complexity. In your last statement in the article, it seems like that sentence above is false. Just because one component is low complexity doesn’t mean the Eval is Low Complexity?

    1. The last statement in this article is true. There are 4 components to the PT evaluation; however, to bill a certain CPT evaluation code, the requirements for all 4 components for that evaluation code must be met. For example, the patient meets the moderate evaluation complexity level for examination, clinical presentation and decision making, but the low complexity for the history. In this example, the therapist would have to bill the low complexity PT evaluation since the moderate criteria for history was not met and documented.

    1. No, because clinical presentation as described in this article only applies to the PT evaluation codes and not the OT evaluation codes.

  3. When billing the new eval codes, and your notes support the complexity that you chose, do you need to have the corresponding number of ICD-10 treatment diagnoses associated in your billing to support the level of complexity you bill? i.e. Moderate complexity total knee replacement: adding ICD-10 for knee pain, abnormality of gait, imbalance along with the medical diagnosis?

    1. The number of DX codes do not have an impact on the complexity level of evaluation that you bill.

  4. First of all, your Webinars are AMAZING. Thank you for taking overly complicated information and making it simple. I have a question on the segment where you talked about the Self care Home management code 97535. We have definitely been using it incorrectly. You say if you are teaching a patient exercises to do at home to bill it as 97110 or 97530 how do you justify that? Is it the amount of time you are telling them / teaching equates to a unit?

    1. Thank you for your kind words. If teaching a patient ROM or strengthening exercises to do at home, those minutes would be counted as therapeutic exercise. If teaching a husband how to get his wife supine to sit and transfer her from the bed to wheelchair, that time would be counted under therapeutic activities. There is no home exercise/patient education code. The minutes spent teaching the patient and/or caregiver are put under the CPT code that best describes what you are teaching them.

  5. Good Morning!! any feedback on the processing and payment of these new codes?? We have some insurances who are rejecting the claims with the new codes.

    1. Most insurance carriers are processing the new evaluation codes without any difficulty. You would need to read the EOB/ERA to determine why the codes are bieng rejected and then contact that insurance carrier.

  6. We are an orthopedic practice having some discussion re the definition of “evolving”. It appears from your examples, it is safe to say evolving does not mean improving??

  7. I have question from an inpatient setting. When the MD orders a PT evaluation, the therapist goes to the unit, does a chart review, and then goes to the bedside for an evaluation. If the patient reports independence with ambulation, do we walk away reporting “no need” and do not charge them? It seems unethical to not evaluate the patient if the MD ordered it and how do we know the patient is truly independent unless we evaluate? Is it unethical to charge that low complexity eval in this instance? Any guidance?

    1. I can’t tell you to evaluate or not evaluate a patient. This is something that needs to be determined by your therapist.