Here’s the Scoop on the New CPT Codes

As we flip our calendars to December, healthcare practitioners have plenty of things to keep tabs on—and that includes the rollout of new CPT codes in the USA for therapy evaluations and re-evaluations on January 1, 2017. That’s right: on New Year’s Day, rehab therapists must stop using all existing evaluative codes—97001, 97002, 97003, and 97004—and begin adopting a set of eight new codes. With the new evaluative coding system, PTs must also choose the correct level of complexity for each patient evaluation. It’s a big change, but I’m confident that with a little planning, we can all make the switch smoothly. On that note, I’ve put together the following overview of the new codes to help get you and your practice on the right track.

Choosing replacement CPT Codes for 97001, 97002, 97003, and 97004

97001

Physical therapists will no longer use the same umbrella code when billing for initial evaluations. Instead, PTs will choose from a set of three different evaluative codes, which are tiered based on their level of complexity. These new codes include:

  • 97161  Physical therapy evaluation: low complexity
  • 97162  Physical therapy evaluation: moderate complexity
  • 97163  Physical therapy evaluation: high complexity

97003

Like their PT counterparts, occupational therapists also have a new set of codes to use when billing for initial patient evaluations. These codes—which are also tiered based on complexity—include:

  • 97165  Occupational therapy evaluation: low complexity
  • 97166  Occupational therapy evaluation: moderate complexity
  • 97167  Occupational therapy evaluation: high complexity

97002 and 97004

PTs will no longer use the same re-evaluation codes when treating patients. However, unlike the new evaluation codes, the new re-evaluation codes are not tiered based on complexity. So, it’s a one-to-one switch for these codes. The new codes are:

97164  Re-evaluation of physical therapy established plan of care requiring:

  1. An examination (including a review of history and the required use of standardized tests and measures); and
  2. A revised plan of care (based on use of a standardized patient assessment instrument and/or measurable assessment of functional outcome).

97168  Re-evaluation of occupational therapy established plan of care requiring:

  1. An assessment of changes in patient functional or medical status, along with a revised plan of care;
  2. An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and
  3. A revised plan of care (a formal re-evaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required).

Determining the right level of code complexity

Choosing the correct code might feel like a bit of a guessing game. But, there are guidelines associated with each level of evaluation complexity. Here are the full details:

New Evaluation Codes – PT (97161)

Low Complexity

  • Typically, the PT spends 20 minutes face-to-face with the patient and/or family.

Moderate Complexity

  • Typically, the PT spends a half hour face-to-face with the patient and/or family.

High Complexity      

  • Typically, the PT spends 45 minutes face-to-face with the patient and/or family.

Re-evaluation

  • Typically, the PT spends 20 minutes face-to-face with the patient and/or family.

PT Evaluation (97161) – Low Complexity

History

  • The patient has a history of the current health issue, but no personal factors and/or comorbidities impact his or her plan of care.

Examination

  • The PT completes an examination of body system(s) using standardized tests and measures addressing one to two elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.

Clinical Presentation  

  • The clinical presentation is stable and/or uncomplicated.

Decision-Making     

  • The PT makes a clinical judgment of low complexity using a standardized patient assessment instrument and/or measurable assessment of functional outcomes.

PT Evaluation (97162) – Moderate Complexity

History

  • The patient has a history of the present problem with one to two personal factors and/or comorbidities that impact the plan of care.

Examination

  • The PT conducts an examination of body systems using standardized tests and measures that address a total of three or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.

Clinical Presentation  

  • The clinical presentation is evolving with changing characteristics.

Decision-Making     

  • The PT makes a clinical judgment of moderate complexity using a standardized patient assessment instrument and/or measurable assessment of functional outcomes.

PT Evaluation (97163) – High Complexity

History

  • The patient has a history of the present problem with three or more personal factors and/or comorbidities that impact the plan of care.

Examination

  • The PT conducts an examination of the patient’s body systems using standardized tests and measures addressing a total of four or more elements from any of the following: body structures and functions, activity limitations, and/or participation.

Clinical Presentation  

  • The clinical presentation is unstable with unpredictable characteristics.

Decision-Making     

  • The PT makes a clinical judgment of high complexity using a standardized patient assessment instrument and/or measurable assessment of functional outcomes.

While it might be fairly easy to flip your calendar to January at the beginning of the year, changing your coding habits might not be so simple. But think of using these new CPT codes as yet another New Year’s resolution—one you, quite literally, simply cannot afford to break. Still have questions? Don’t miss WebPT’s next live webinar, “New Year, New Codes,” which takes place Thursday, December 15, 2016. During this 90-minute presentation, I’ll partner with compliance guru Rick Gawenda to offer a comprehensive overview of the new CPT codes and explain how to determine the right level of complexity for each patient evaluation. Remember, come 2017, these new CPT codes will take control of the proverbial power grid—so don’t let your billing knowledge shut off over the holidays.

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Comments

John Sabulis
John Sabulis
December 1, 2016 at 10:09 am

Thanks for this. Physicians have had these graded visit complexity codes for awhile . It seems these new codes will recognise the differences in patient complexity, especially as the population ages. More than ever it will be useful to use subjective testing such as the FABQ and min-mental tests to capture barriers to progression which are not just based on dx and functional limitations.

Heidi Jannanga

I agree – if PTs and OTs embrace this coding change and put forth a good faith effort to code accurately, the data we collect could have a significant impact on population health, as it would allow us to get even more granular in cross-comparisons and better inform future treatment based practices. I also agree that patient complexity encompasses a host of factor, including but not limited to subjective testing and co-morbidities. However, it is important to remember that this is about complexity of treatment or in this case, evaluation not merely the complexity of the patients themselves (for example, you could have a very complex patient who requires non-complex treatment). Still, this change will definitely help us add to the data we have available for analysis which in turn gives us better insight into the patients we are serving. Now, it’s just a matter of getting the entire profession on board with this change. Thank you for the comment!

CG Walker
CG Walker
January 12, 2017 at 8:44 pm

Can anyone give me any insight into why a low Complexity OT eval (97165) cannot be billed with Moderate or High Complexity PT evals? Does it matter if they are done on separate days?

WebPT
January 17, 2017 at 7:08 pm

The new codes are considered “mutually exclusive” because when a PT and OT are seeing a patient as a team, they cannot bill separately for that time. However, if the two services are provided on different dates of service—as part of different plans of care—then they should be separately billable. Hope that answers your question.

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