Who Do The New Evaluation Codes Apply To

November 21, 2016
 / 
Rick Gawenda
 / 

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? In this article, I will answer the following:

  1. What insurance carriers will use the new evaluation CPT codes?
  2. Will workers compensation and auto no-fault carriers recognize and use the new evaluation codes?
  3. In what outpatient therapy settings will the new evaluation CPT codes be required?
  4. Will providers of inpatient services be required to use the new evaluation CPT codes?

What insurance carriers will use the new evaluation CPT codes?

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  1. For private insurance auths – do we need to get auth for all 3 codes or just 1. Hard to tell before we actually see the patient. Thanks.

    1. You would need to check with the insurance carrier. My hope is they just approve the initial evaluation and as long as you bill one of the evaluation codes, you would be paid.

  2. ASHT is stating that the NPI number must be attached to the new CPT codes as part of the written eval. My understanding is the NPI is attached to the billing (and therefore code). Has any different information come out in regards to NPI and the new CPT codes?

  3. Do you see any negative outcome to establish your pricing for the new eval codes at different price points? We have some contracts that pay on a percent of total billables.
    Thanks!