How to bill for Physical Therapy and Outpatient Therapy evaluations in 2017

How to bill for Physical Therapy and Outpatient Therapy evaluations in 2017

PT billing software will now have to be used differently. This does not mean you have to redesign your notes, you just have to be conscious of the New Evaluation codes. As of January 1, 2017, Physical Therapists (PT) and Outpatient Therapists (OT)  have to get used to billing for new therapy evaluations and re-evaluations (in their web based practice management software). CPT which is the set of medical code used to report medical, surgical and diagnostic procedures and services to physicians, health insurance companies, and accreditation organizations has gotten updated. With this modernization, the use of old codes that PTs and OTs have come to know and love – 97001, 97002, 97003, and 97004 will be forever gone (right now you may still need to use both). PT’s and OT’s will now have to get an understanding of CPT’s new eval and re-eval guidelines to get their needed documentation for a hassle-free claims submission. While the new codes bear a resemblance to E&M codes, they fluctuate in terms of complexity, necessity, and documentation.

Significant Newness

  • The new evaluation codes with not require specific evaluation forms to be completed.
  • The therapist’s clinical judgement in determining treatment inventions will need to be documented.
  • There is no specific word or phrase that will justify the code usage.
  • There is a “Typical face to face time” to consider when determining the overall code value.
  • All “HIPAA” covered entities will be required to use the new codes.
                             -meaning everyone except workers comp and MVA claims

New update requirements:

97001 no longer valid (PT)

Earlier PT’s applied the same evaluation code for every patient. Now, they will have to choose from a set of three different evaluative codes depending on the complexity of the evaluation.

97161: low complexity (here the PT meets with the patient/family for 20 minutes, and personal factors or comorbidities has not changed the current plan of treatment)

97162: moderate complexity (The PT spends 30 minute face-to-face with the patient and/or family. The patient has a history of the present problem and a history of 1-2 personal factors and/or comorbidities that affect the plan of care)

97163: high complexity (45 minutes face-to-face with the patient and/or family, a history of the present problem with 3 or more personal factors and/or comorbidities that impact the plan of care)

97003 no longer valid (OT)

Similarly, OT’s will bill patients according to the severity of the evaluation dislodging the old system of using the same code for every patient.

97165: low complexity (30 minutes face-to-face with the patient and/or family, identifies 1-3 performance deficits that could be physical, cognitive, or psychosocial and curb activity)

97166: moderate complexity (A 45 minutes face-to-face between the OT and the patient and/or family. The patient’s occupational profile and medical and therapy history includes an expanded review of medical and/or therapy records and additional analysis of physical, cognitive, or psychosocial history related to current functional performance)

97167: high complexity (60 minutes face-to-face with the patient and/or family. The patient’s occupational profile and medical and therapy history includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance)

97002 and 97004 no longer valid (PT and OT re-evaluations)

Unlike the evaluations codes which are tiered according to difficulty, there is just one replacement code for 97002 and one for 97004.

97164 is the new code for a re-evaluation of physical therapy. What does it cover?

  • Involves examination, history review, standardized tests and measures
  • Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome
  • An untimed code, typically 20 minutes are spent face-to-face with the patient

97168 is the new code for a re-evaluation of OT. What does it cover?

  • Involves an assessment of changes in patient functional or medical status and includes a revised plan of care
  • Update to the original occupational profile including any changes in condition or environment that  would affect future interventions and/or goals
  • A revised plan of care. It must involve a formal re-evaluation and a documented change in functional status or a significant swift to the plan of care that is required.

Validate your choice

In order to validate your choice of the evaluation code your evaluations must include the following elements

  • Patient history/ Personal factors and/or comorbities
  • Examination of body system(s)
  • Clinical presentation
  • Clinical decision making (complexity)

Patient History/Personal factors and/or comorbidities

  • Documenting the relevant history
  • Comorbidities that impact function and ability to progress
  • Previous functional level as compared to current functional abilities
  • Social history, living environment, work status, cultural preferences, medications, as well as cognition

Examination/ Body system(s) using standardized tests and measures

  • Body structure: Structural or anatomical parts of the body
  • Activity limitations: Difficulties executing tasks, actions or activities
  • Body systems review: As appropriate, cardiovascular/pulmonary, integumentary, musculoskeletal, neuromuscular (balance, gait, coordination, motor control)
  • Use of standardized tests and measures
  • The number of body regions evaluated (body regions defined as head, back, lower extremities, upper extremities, and trunk)

Patient’s Clinical Presentation

  • Element 3 in determining the level of complexity is clinical presentation
  • Physiological changes such as pain, swelling, blood pressure, pulse, sweating, etc.
  • Stable, uncomplicated, predictable
  • Evolving clinical presentation with changing characteristics
  • Unstable and unpredictable characteristics (unstable and unpredictable)

Clinical Judgement/Decision Making / COMPLEXITY

Element 4 is related to ‘judgement and decisions’.

  • Low severity would likely consist of the use of 1 or 2 standardized tests and measures. Typically, 20 minutes are spent face-to-face with the patient.
  • Moderate severity would likely utilize 3 or more standardized tests or measures. Typically 30 minutes are spent face-to-face with the patient.
  • High severity would utilize 4 or more standardized tests and measures. Typically 45 minutes are spent face-to-face with the patient.

Clinical judgment will play a huge role in this new code selection, and proper documentation must support the code you have chosen.

Patients need to note that the codes will be valued at current rates. For instance, a patient’s reimbursement for treatment that would have registered in the now defunct code ‘97001’ will remain the same when registered under the new codes 97161, 97162, and 97163.