New PT & OT Evaluation Codes Begin January 1, 2017
Beginning with dates of services on and after January 1, 2017, physical and occupational therapists will have new CPT codes to report their respective evaluations to the insurance carrier. For physical therapists, CPT code 97001 (Physical therapy evaluation) is being deleted and replaced with three new CPT codes. The three new CPT codes are:
97161 – Physical therapy evaluation: low complexity
97162 – Physical therapy evaluation: moderate complexity
97163 – Physical therapy evaluation: high complexity
For occupational therapists, CPT code 97003 (Occupational therapy evaluation) is being deleted and replaced with three new CPT codes. The three new CPT codes are:
97165 – Occupational therapy evaluation, low complexity
97166 – Occupational therapy evaluation, moderate complexity
97167 – Occupational therapy evaluation, high complexity
Now that we know what the CPT codes are, who will be using the new CPT codes and how will they be paid? In this article, I will answer the following questions:
- What insurance carriers will use the new evaluation CPT codes?
- Will workers compensation and auto no-fault carriers recognize and use the new evaluation codes?
- In what outpatient therapy settings will the new evaluation CPT codes be required?
- Will providers of inpatient services be required to use the new evaluation CPT codes?
- How will the Medicare program pay for the new evaluation codes?
- Can you provide some examples of payment rates for the new PT and OT evaluation codes?
- How will private insurance carriers and state Medicaid programs price the new PT and OT evaluation codes?
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Hello Rick, Thank you for the info on the new eval codes. What do you suggest should be our charge/billing price for each code? Same for all 3 or in a hierarchy? thanks in advance for your advice.
My opinion is to have different prices for the different eval codes.
I work as a Pediatric PT in an Early Intervention program where we are required to use the HELP or IDA to determine eligibility for services. Neither are standardized evaluation tools. Are there any guidelines for pediatrics with the new evaluation codes? Thank you.
Nothing states you must use a standardized outcome measure. What you do use are standardized tests and measures and may use outcome tools in addition to standardized tests and measures.
Will a standardized outcome tool or patient assessment tool be completed and documented for every patient? Can you provide some examples of assessment tools?
the clinical decision making component of each code states “…using standardized patient assessment instrument and/or measureable assessment of functional outcome.”
So does this mean a tool must be completed and documented? or do standard tests and measures (MMT, ROM, special tests) meet this requirement?
The answer to your question can be found at the following link:
http://gawendaseminars.com/pt-ot-eval-codes/
The answer to your question can be found at the following link:
http://gawendaseminars.com/pt-ot-eval-codes/
are these reimbursements medicare and I need to make my fee schedule based on these, Anywhere to find the information for Kentucky
Click on the link below.
http://gawendaseminars.com/2016/current-news-posts/2017-physician-fee-schedules-released/
Can we bill the new evaluation codes with treatment codes(ie 97116, 97530, 97110)on the same day?
CCI Edits Version 23.0 is on my website at the following link:
http://gawendaseminars.com/medicare-cms-cci-edits/
One of my peers listened to your “2017 new eval codes” seminar (I also listened in Novemmber) and got the impression that you have to code the new eval codes based off of the lowest scoring component of the eval (history & co-mobidities, exam elements, clinical presentation & clinical decision making). So, for example, if you had a patient with no co-morbidities that impact the plan of care (low), but had 6 elements in the exam (high), felt their clinical presentation was evolving (moderate), and felt the clinical decision making was moderate, and it took you 45 minutes to do the eval —still have to bill the Low eval CPT code because there were no co-morbidities…Can you site the CPT literature that supports that you have to bill the CPT eval code that is equal to the lowest graded section???
It is in the CPT book under the heading “Physical Therapy Evaluations”
One of my peers listened to your “2017 new eval codes” seminar (I also listened in Novemmber) and got the impression that you have to code the new eval codes based off of the lowest scoring component of the eval (history & co-mobidities, exam elements, clinical presentation & clinical decision making). So, for example, if you had a patient with no co-morbidities that impact the plan of care (low), but had 6 elements in the exam (high), felt their clinical presentation was evolving (moderate), and felt the clinical decision making was moderate, and it took you 45 minutes to do the eval —still have to bill the Low eval CPT code because there were no co-morbidities…Can you site the CPT literature that supports that you have to bill the CPT eval code that is equal to the lowest graded section???
Reply
Rick Gawenda says:
December 21, 2016 at 7:20 pm
It is in the CPT book under the heading “Physical Therapy Evaluations”
The above scenario just came up again in some recent training. I do not see anything that speaks to choosing the lowest code in the AMA CPT book in physical therapy evaluations. Could you clarify?
That is correct and the reference is the annual CPT book where AMA states the following: at a minimum, each of the following components noted in the code description must be documented in order to report the selected level of physical therapy evaluation. The same language also appears right before the OT evaluation codes.
Thank you for the clarification. I was interpreting that differently.
I work in an acute care Level II trauma center. Am I understanding this correctly? If a pt had zero comorbidities before their accident, regardless of how badly they are injured and extensive the PT Plan of Care is for their rehab, they will automatically be a “Low Complexity”? Once this patient then transfers to OP rehab, will they stay a low complexity since their injuries were all related to this single MVA and not a true comorbidity?
Keep in mind that the new evaluation codes apply to the outpatient therapy setting. In the inpatient setting, you are not billing via CPT codes and/or being paid by CPT codes by the vast majority of insurance carriers. In a true acute care setting, you are paid via DRG’s. If an insurance carrier does pay via CPT codes or the patient is switched from inpatient to outpatient status, then the new evaluation and reevaluation codes would apply.
Hey Rick
Do you have a cheat sheet for the new eval codes, like you do for CCI edits. Anything like the slides you prepared for the Web PT webinar where each component had the list of data that supported that particular component complexity and then was categorized for low, med or high complexity. It seemed easier to decide what the overall eval complexity is when each component was laid out.
Please read the article below.
http://gawendaseminars.com/2016/current-news-posts/new-evaluation-codes-officially-released-by-the-ama/
The new CPT codes read that a component of charging a re-eval is when a plan of care is revised. The PT CPT code just reads “revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome” and the OT CPT code reads “A revised POC. A formal revaluation is performed when there is a documented change in functional status or a significant change to the POC is required”. Currently we can only charge a re-eval if the POC is changed due to a status change, but with the change in codes can it be charged anytime a POC is created?
To charge a reevaluation, it must meet the criteria to bill a reevaluation. To see the criteria, click the link below:
http://gawendaseminars.com/2016/current-news-posts/new-reevaluation-codes-to-begin-january-1-2017/
Can the new eval codes for PT or OT be used more than once in the same episode of care, or should the re-evaluation code be used? We have this question coming up frequently in our inpt setting even though the facility is being reimbursed via DRG, we use the OP coding structure and rules. In this scenario, a patient is seen and evaluated, treated and discharged by PT but while still admitted in the hospital the patient must resume PT care for mobility or something different such as wound care. In this example, should the PT utilize the re-evaluation code or can they use one of the new eval codes again? Thanks
You would need to determine if it is a reevaluation or a new condition on a new evaluation. As you stated, in the inpatient setting, you are not paid via CPT codes, rather, by DRGs.
If a patient is seen in an outpatient PT setting, gets referred to an ortho, undergoes surgical repair, and presnets back to therapy, is the correct code a Re-eval or can an eval code be charged (despite an eval being charged several weeks prior).
The therapist would need to determine if this is an evaluation or a reevaluation due to a significant change in the patient’s function and/or status or there are now new clinical findings that are present.
Rick the cci edit shows the new eval PT codes and OT codes cannot be billed on the same day and doesn’t not allow a modifier. This is a concern as we often have patients needing both PT and OT. Having them one two separate days is not convenient for the patient. Did I miss read the edits?
In a private practice setting, the PT and OT should be billing on separate 1500 claim forms under their respective NPI number in box 24j with the payment reassigned to the group NPI in box 32 and 33. The issue is for PT and OT practicing in a physician owned practice and billing incident to the physician. In the non-private practice version, there is also an issue when PT bills CPT code 97162 and OT bills either 97165 or 97166.
I believe CMS has been made aware of this and is in the process of correcting with the Medicare Administrative Contractors for the first quarter of 2017. We should see the correction in Version 23.1 which becomes effective April 1, 2017. Hope this helps.
I know you touched briefly on this in the Q+A portion of the webinar.
I work in a private practice setting where we have occupational therapists working as CHTs. We do not have access to medical records. How can we avoid making every OT evaluation a low complexity evaluation when we do not have access to medical records?
Nothing in the OT codes state they have to be records from an outside organization or practice. It could be a review of your staff with the patient and/or their family or caregiver(s).
Thanks!
Wondering if you have any guidance with determining productivity associated with the new eval CPT codes? With the 2016 codes, our organization assigned 4 units of productivity with 97001 and 97003 untimed codes.
Each organization would need to determine productivity standards for the new PT and OT evaluation codes.
Hi, thank you for great info. Heads up, we have a denial of the new evaluation codes from Blue Cross – northern CA. Heard any news regarding this issue?
I am billing from a private outpatient clinic setting – electronic. Bills from Jan 3 rejected at BC.
To me, that is not surprising as insurance carriers may be behind in implementing the new evaluation and reevaluation CPT codes. I expect we will see this from other insurance carriers across the United States.
To me, that is not surprising as insurance carriers may be behind in implementing the new evaluation and reevaluation CPT codes. I expect we will see this from other insurance carriers across the United States.
The New evaluation codes have not been added to the northern CA Blue Shield either – denied at Office Ally, but their customer service was notified today that they are suppose to use the codes but they are not currently on the fee schedule. From Redding CA – Office ally rejected the claim
To me, that is not surprising as insurance carriers may be behind in implementing the new evaluation and reevaluation CPT codes. I expect we will see this from other insurance carriers across the United States.
I copied the codes from your site – insurance by state and CPT’s on FEE Schedule – had my staff call several times to get a rep from BS and BC that would accept and e mail of their information from their site and now re processing begins. Thank you for the info that is quick to access and use. We bill daily so our turn around is fast and fixable. Thank you
You are welcome! Thank you for the positive feedback.
Hello, I appreciate you sharing your thoughts and knowledge regarding charging and billing. We are trying to determine when to use the High complexity code in outpatient. An example: a pt being seen for neck pain but presenting with HTN. BP in clinic after exercise is as high as 180/110.
Even though we are not treating the HTN specifically, does this co morbidity mean that this falls into the high complexity category for clinical presentation?
THank you!
To bill CPT code 97163, patient would need 3 or more personal factors and/or co-morbidities documented that you feel will impact the plan of care, 4 or more elements and measures from body systems, body functions and/or activity limitations and/or participation restrictions and have a clinical presentation that is unstable or unpredictable.
would uncontrolled HTN when treating an orthopedic injury qualify as unpredictable and unstable? thanks you
The answer can be yes or no. It is up to the evaluating therapist to make that determination and support it by their documentation in the medical record.
one more question that I have struggled with … when coding, should I include a HTN ICD 10 code? I really appreciate your insight!
That would be a decision you have to determine. Obviously, the diagnosis of HTN would be given by a physician and would have to be confirmed.
Thank you