New PT & OT Evaluation Codes Released

July 7, 2016
Rick Gawenda

Today, the Centers for Medicare and Medicaid Services released the 2017 proposed rule for services paid under the Medicare Physician Fee Schedule. This proposed rule includes the long awaited new evaluation and reevaluation codes for physical and occupational therapy services. The proposed rule provides the 3 new physical therapy evaluation codes, new physical therapy reevaluation code, 3 new occupational therapy evaluation codes and the new occupational therapy reevaluation. The proposed rule provides the long descriptor of each new code along with the components required in the documentation to support the selection of each code.

The new codes along with their long descriptor are:

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  1. If passed (October?) when will the codes be effective/billable? Will the codes only apply to Medicare?

    1. The new evaluation and reevaluation CPT codes will become effective January 1, 2017 and will apply to all HIPAA covered entities, that does include the majority of private and commercial insurance carriers.

  2. Does the RVU determine the monetary reimbursement of the codes? If they all are valued the same, why is there a difference in the expected face-to-face time? Wasn’t the intent of our proposal to create more appropriate reimbursement based on patient complexity?

    1. The RVU’s for work expense, practice expense and malpractice expense are what determines the payment for each CPT code. Since CMS is proposing to have the work and practice expense values be the same for all 3 PT eval codes and all 3 OT eval codes, assuming the malpractice RVU is the same for all 6 codes, payment will be the same regardless of the complexity of the patient and clinical decision making of the therapist.

    2. The RVU determines the payment for the CPT codes. The intent of the new evaluation codes was to have different payment dependent on the severity and complexity of the patient and the time required to perform the evaluation as well as the clinical decision making of the therapist.

  3. I see CMS is accepting comments until September – does that mean things could still change or should we be considering this a reality as of January?

    1. As you state, the rule is proposed as of now and CMS is accepting comments. That means there is a possibility that the final rule can change from the proposed rule that was published. In my opinion, I think it will be difficult for all of us, including our national professional associations (APTA and AOTA) to persuade CMS to change the work and practice expense RVU’s differently for the 3 new evaluation codes.

  4. The codes are listed with “X” in the the 3rd position. For example, 97X61. is this the complete listing of the code? Or is the “X” a place holder?

    1. The “X” is a placeholder. Most likely the third digit will be a “1”, but we have to wait until the codes are officially released by the American Medical Association.

  5. As a Rehab Agency we bill as Part A Medicare but are reimbursed under Part B Medicare so are we included in these new CPT Codes?

  6. Most commercial payers use the CPT codes for inpatient therapy claims. If the current codes, ie, 97001, etc will not be in the 2017 CPT code listing and replaced with the new codes, inpatient claims will be submitted using the new eval codes also. is that correct?
    Thank you!

    1. Social factors, medications, past medical history, past surgical history, family support, etc.

  7. Will the changes affect the treatment portion of a patient’s visit? Early information suggested per session reimbursement rather than the traditional per unit reimbursement.

  8. Do you anticipate any scenarios where the complexity of a PT evaluation would vary from the complexity of an OT evaluation? For example, the OT scored the eval as low complexity and the PT as high based on each discipline’s involvement.

    1. The components for the PT evaluation and OT evaluation are different and you can’t compare the 2. To answer your question, a situation could occur, for example, where the OT bills a low complexity evaluation and a PT bills a moderate complexity evaluation or vice versa. This is just one example. Documentation in the medical record would support the level of evaluation billed for each discipline.