Preparing for the New CPT Codes (with Complexity Criteria Examples)

With great power comes great responsibility. You’ve undoubtedly heard this phrase many times in the past, and there’s no better time than the present to take that wisdom to heart. After all, the new CPT codes for therapy evaluations and re-evaluations are in effect as of January 1, 2017. While PTs and OTs will certainly have more power when it comes to accurately describing the patients they treat and the services they provide, they also will be responsible for determining—and coding for—the correct level of complexity associated with each patient evaluation. And that’s going to require some extra time and work. Power and responsibility: a double-edged sword.

Now, you may be thinking that you don’t want the power or the responsibility associated with these new codes. And while I don’t blame you entirely, I do think that we, as an industry, should acknowledge that this may end up being the start of something great for us. Because eventually—not today, and maybe not even tomorrow, but eventually—our ability to create more complete pictures of the patients we treat and the services we provide could have a very positive impact on our reimbursement rates.

With that in mind, here are two examples of how to accurately code for the correct level of evaluation complexity. (If you haven’t done so already, you may want to read this blog post before digging into these examples; it’ll provide the context you need to define the characteristics of each level of complexity.)

Patient Example 1

For the last two weeks, Matt (age 53) has been experiencing low back pain, which has caused him occasional discomfort. However, his condition has steadily worsened over the past couple of days, and the pain has spread to the top and sole of his right foot. As a result, he’s missed his daily two-mile jog, woken up between three and four times per night, and been feeling restless each morning before work. At his first PT appointment, Matt rates his pain level as a “six” on a ten-point scale. After performing several tests on Matt’s lower back and limbs, the PT realizes that Matt has decreased sensation to light touch and pin-pricks on the top and bottom of his right foot. He can’t sit or stand for more than half an hour at a time—nor can he lift heavy weights—which leaves him with a 44% score on the Oswestry.

Here’s the example broken down in chart form:

Duration: The PT spends 30 minutes of face-time with Matt and his family.

History: While Matt has a history of low back pain, he has no personal factors or comorbidities that would impact his plan of care, which means that his pain most likely resulted from an injury or accident—as opposed to an underlying health issue.

Examination: Matt’s PT completes an examination of his lower back and extremities, using standardized tests and measures that address:

One body structure (e.g., lumbar vertebral column)

Two body functions (e.g., muscle power and sensation and pain)

One activity limitation (e.g., mobility: walking, carrying, and sleeping)

Clinical Presentation: Matt’s clinical presentation is stable and uncomplicated.

Decision-Making: During the evaluation, the PT exercises low complexity clinical decision-making, using standardized patient assessment instruments and measurable assessments of Matt’s functional outcomes.

Correct Code: 97161 (Low-Complexity PT Evaluation)

While Matt has a history of low back pain, he didn’t present with any personal factors or comorbidities that would impact his plan of care—and his condition doesn’t largely restrict his daily performance and activity levels. With this in mind, it makes sense to code for low complexity (at least at this point in Matt’s course of treatment).

Patient Example 2

Nine weeks ago, Jane (age 82) had a stroke, after which she spent 12 days in an inpatient rehab facility before being transferred to a skilled nursing facility to receive five weeks of continued treatment. Today, Jane is living with her 53-year old daughter—who provides routine care and assistance—and receiving occupational therapy in her home. Five months ago, Jane lost her husband and is having trouble coping with his absence. Prior to her stroke, she was attending a grief support group; however, she has been unable to attend since her stroke. Jane also is legally blind, has type-1 insulin-dependent diabetes, and had a knee replacement last year. She is presenting with short-term memory deficits, a decreased ability to complete tasks, muscle weakness, a hemiplegic gait pattern, and proprioceptive deficits on her right side. As a result, Jane is no longer able to perform household chores like vacuuming and doing her own laundry. These restrictions also have forced the OT to provide assistance and modify some evaluation activities during visits.

Here’s the example broken down in chart form:

Duration: The OT spends 45 minutes of face-time with Jane and her daughter.

History: To establish Jane’s plan of care, the OT conducts an extensive review of her medical and therapy records. During that review, the OT discovers that Jane recently received care at an inpatient rehab facility, a skilled nursing facility, a psychologist’s office, and a social work office. Additionally, Jane’s legal blindness and decreased mobility result in limited functional performance.

Examination: Jane’s OT completes an examination of the areas in which she is experiencing pain using standardized tests and measures that address:

Seven performance deficits (e.g., dressing, bathing, toileting, walking, getting in and out of bed, getting transferred from one location to another, and performing everyday activities.)

Decision-Making: During her evaluation, the OT exercises moderately complex clinical decision-making using standardized patient assessment instruments and/or measurable assessments of Jane’s functional outcomes.

Correct Code: 97166 (Moderate-Complexity OT Evaluation)

Because Jane has such an extensive history of physical, cognitive, and psychosocial challenges that impact her current functional abilities, the OT must conduct an intensive review of her records. Additionally, in the assessment, the OT finds seven performance-related deficits currently hindering Jane’s ability to complete routine activities and household tasks. However, despite the fact that the number of performance deficits is greater than the number included in the code description for a moderate-complexity evaluation, Jane’s evaluation—on the whole—is not complex enough to warrant a high-complexity code. (Remember, when there are elements of different levels of complexity in an evaluation, you typically should code down.) Thus, the OT should code for moderate complexity.

Keep in mind that these examples are purely hypothetical—and they’re only examples. No two patients will present exactly alike, and there is no plug-and-play tool to help you select the correct level of complexity for every evaluation. As is the case with ICD-10 code selection, it’s ultimately up to the PT or OT to use his or her clinical judgment and expertise to select the appropriate complexity category for every patient evaluation. And to do that, you must diligently collect as much pertinent information from your patients as possible.

To learn more about applying the new complexity criteria to your patient evaluations, watch this free webinar compliance expert Rick Gawenda and I co-hosted earlier this month. Then, check out this FAQ document.