New Physical Therapy Evaluation and Reevaluation CPT Codes | | Medical Practice Consultant

2017 New Physical Therapy Evaluation Codes

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Effective January 1st 2017, we have 3 New Physical Therapy Evaluation Codes

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Key Points:

1. Each of these codes are not “time-based”; “typical time” is used as a guidance only

2. Complexity (low-medium-high)3. Therapy Evaluation encounter MUST meet Medical Necessity and clearly

documents FUNCTION4. Use these new therapy evaluation codes for Medicare and commercial payers;

Workers’ Comp and MVA liability may still be using 97001/970025. CPT Code 97001 is DELETED and REPLACED by 3 new physical therapy

evaluation Codes6. CPT Code 97002 is DELETED and REPLACED by one single re-evaluation code



These New Physical Therapy Evaluation Codes has

4 Components of Complexity and Severity



1. Patient Medical and Functional HISTORY, which includes relevant comorbities and personal factors; Comorbities/pre existing conditions that affects function and ability to progress through a plan of care

● History of Functional limitation(s) and level; current functional level, abilities and limitations

● Identify and Document Personal Factors that may impact the plan of care for Physical Therapy treatment; eg. age, gender, social history, education background, lifestyle, coping styles, job/profession, present/past experience. Document the overall behavior patterns including experience with disability;

● Existing personal factors that will not impact the plan of care should not be used when selecting the level of service



2. Examination of body system(s) using standardized tests and measures;Body Structures:

● Anatomical or structural parts of the body, eg., the organs, limbs and their components, classified according to the body systems;

Body Regions: ● Includes the Head, neck, back, lower extremities, upper extremities and trunk

Body Systems:● Musculoskeletal (range of motions, strength, weight/height, symmetry)● Neuromuscular (coordinated physical/body movement which includes gait

transfers, locomotion and transitions) and motor functions on control and learning● Cardiovascular Pulmonary (RR, HR, BP and Edema)● Integumentary (skin integrity, texture, presence of scar formation)● Review of Systems should also include orientation of person, place and time;

consciousness, the ability to express/show needs, anticipated emotional and or behahavioral responses



3. Clinical Presentation of the patient● Stable and uncomplicated, OR● Evolving clinical presentation with changing clinical

characteristics OR● Evolving clinical presentation with unstable and

unpredictable characteristics



4. Clinical Decision Making (based including the utilization of standardized patient assessment tools and or using the Functional Outcome measurable assessment result)

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



CPT Code 97161● 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.



CPT Code 97162● 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




CPT Code 97163● 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




ONE SINGLE CODE FOR PHYSICAL THERAPY RE-EVALUATION

CPT CODE 97164



CPT Code 97164● 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.



KEEP IN MIND!



➔ 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.

➔ Since these codes are untimed codes, the time (minutes) rendered during the evaluation are now part of the “total minutes” of treatment time – this includes both the untimed and timed codes.



➔How about CMS REIMBURSEMENT?The 3 New Physical Therapy Evaluation codes are being reported based on its Complexity, they are priced based on a group than per code. Reimbursement is the same on each level/code.



The Medicare therapy cap has increased from $1960 in 2016 to $1980 in 2017.

And the 2017 Medicare conversion factor is $35.88, a $0.05 increase from 2016



GOT MORE QUESTIONS?



References:● 2017 CPT Manual (CPT is a Trademark and Owned by the American Medical

Association)● http://www.apta.org/uploadedFiles/APTAorg/Payment/Reform/

NewEvalCodesQuickGuide.pdf● https://www.cms.gov/Medicare/Billing/TherapyServices/index.html?redirect=/

therapyservices


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New Physical Therapy Evaluation and Reevaluation CPT Codes | | Medical Practice Consultant