August 10, 2016

New Physical Therapy Evaluation Codes for 2017

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The Centers for Medicare & Medicaid Services (CMS) has proposed new physical therapy and occupational therapy evaluation codes for 2017 as part of the Medicare Physician Fee Schedule proposed rule for 2017 (CMS-1654-P). The therapy community has long been awaiting these anticipated changes to the current CPT® coding structure. Specifically, the proposed rule provides information on the new physical therapy and occupational therapy evaluation codes.

There are three new physical therapy evaluation codes and one new physical therapy re-evaluation code. The codes are based in large part on the amount of time and complexity involved in the evaluation. The table below identifies the new physical therapy codes for 2017 and gives the long-form description of each code.

New CPT Code

CPT Long Form Descriptor

97X61

Physical therapy evaluation: low complexity, requiring these components:

  • A history with no personal factors and/or comorbidities that impact the plan of care;
  • An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
  • A clinical presentation with stable and/or uncomplicated characteristics; and
  • Clinical decision-making of low complexity using a standardized patient assessment instrument and/or measurable assessment of functional outcome.
  • Typically, 20 minutes are spent face-to-face with the patient and/or family.

97X62

Physical therapy evaluation: moderate complexity, requiring these components:

  • A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;
  • An examination of body systems using standardized tests and measures in addressing a total of three or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
  • An evolving clinical presentation with changing characteristics; and
  • Clinical decision-making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
  • Typically, 30 minutes are spent face-to-face with the patient and/or family.

97X63

Physical therapy evaluation: high complexity, requiring these components:

  • A history of present problem with three or more personal factors and/or comorbidities that impact the plan of care;
  • An examination of 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 restrictions;
  • A clinical presentation with unstable and unpredictable characteristics; and
  • Clinical decision-making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
  • Typically, 45 minutes are spent face-to-face with the patient and/or family.

97X64

Re-evaluation of physical therapy, established plan of care, requiring these components:

  • An examination, including a review of history and use of standardized tests and measures is required; as is a
  • Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome.
  • Typically, 20 minutes are spent face-to-face with the patient and/or family.

These new codes are all untimed codes, and when recording time for Medicare, the minutes allocated for the evaluation are tallied as part of the “total treatment minutes,” which includes timed codes and untimed codes. CMS has proposed the same payment for each code because of its concern for upcoding opportunities (in other words, the agency is skeptical that therapists will use each code appropriately). It is important for therapists to begin to assess patient evaluations and begin to gain the skill to determine the appropriate level of codes based upon the components as well as the typical time frame that is inherent in the CPT code description. Although CMS is proposing a single payment for the three evaluation codes, it has made it clear that it will be assessing usage of each code via the claims system (“code-speak,” for data analytics.

According to CMS, the CPT Editorial Panel’s creation of the new PT and OT evaluative procedures codes grew out of a CPT workgroup originally convened in January 2012, at a time when CMS was contemplating major revisions of the Physical Medicine and Rehabilitation CPT section of codes. This was in response to CMS identifying therapy codes as potentially "mis-valued" codes, including CPT code 97001 and the other PT/OT evaluative codes in the 2012 PFS proposed rule.

Stay tuned for my next article, where I will cover the proposed new occupational therapy evaluation codes.

About the Author

Nancy Beckley is founder and president of Nancy Beckley & Associates LLC, providing compliance planning and outsourced compliance services to rehab providers in hospitals, rehab agencies, and private practice. Nancy is certified in healthcare compliance by the Healthcare Compliance Certification Board. She is on the board of the National Association of Rehabilitation Providers and Agencies. She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities. Nancy is a familiar voice on Monitor Monday where she serves as a senior national correspondent.

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nancy@nancybeckley.com

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Nancy J. Beckley, MB, MBA, CHC

Nancy Beckley is founder and president of Nancy Beckley & Associates LLC, providing compliance planning and outsourced compliance services to rehab providers in hospitals, rehab agencies, and private practices. Nancy is certified in healthcare compliance by the Healthcare Compliance Certification Board. She is on the board of the National Association of Rehabilitation Providers and Agencies. She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities. Nancy is a familiar voice on Monitor Mondays, where she serves as a senior national correspondent.

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