New PT & OT evaluation and re-evaluation codes

new-pt-ot-evaluation-and-re-evaluation-codesOn July 7, CMS released information on the proposed new PT and OT evaluation and re-evaluation codes. CMS will finalize these codes and their reimbursement levels in November to be effective January 1, 2017.

There are three proposed PT eval codes, three OT eval codes, and one new re-eval code for each discipline which replace codes 97001 through 97004. While there are three evaluation codes, one each for low complexity, moderate complexity and high complexity, CMS is proposing that they all be valued the same, and hence reimbursement will be the same for all three. The proposed unit values and reimbursement will be very similar, if not the same, as the current eval and re-eval codes. You can count on that once CMS obtains enough data about the usage of these codes, they may adjust their values in later years.

CMS is says “the following codes are misvalued”: 97032 e-stim, 97035 ultrasound therapy, 97110 therapeutic exercises, 97112 neuromuscular re-ed, 97113 aquatic therapy/exercises, 97116 gait training, 97140 manual therapy, 97530 therapeutic activities, 97535 self care management training, G0283 elec stim other than wound care. This means these codes are used too much or are paid out at to high of a value

The table below shows the proposed PT and OT codes and their descriptors.

New PT & OT CPT Eval & Re-Eval Codes CPT Long Form Descriptors for Physical Medicine and Rehabilitation
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;
    • Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
    • A clinical presentation with stable and/or uncomplicated characteristics; and

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 3 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 evaluationhigh complexity, requiring these components:

  • A history of present problem with 3 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 4 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 Reevaluation 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; and
  • 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.
97X65 Occupational therapy evaluation, low complexity, requiring these components:

  • An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem;
  • An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.
    Typically, 30 minutes are spent face-to-face with the patient and/or family.
97X66 Occupational therapy evaluation, moderate complexity, requiring these components:

  • An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance;
  • An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or
    psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.
    Typically, 45 minutes are spent face-to-face with the patient and/or family.
97X67 Occupational therapy evaluation, high complexity, requiring these components:

  • An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance;
  • An assessment(s) that identify 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • A clinical decision-making is of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.
    Typically, 60 minutes are spent face-to-face with the patient and/or family.
97X68 Reevaluation of occupational therapy established plan of care, requiring these components:

  • An assessment of changes in patient functional or medical status with revised plan of care;
  • An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and
  • A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.
    Typically, 30 minutes are spent face-to-face with the patient and/or family.