As soon as the New Year began, 4 therapy service CPT(R)* codes (97001-07004) were deleted, and 8 new therapy service codes (97161-97168) became effective for physical therapy (PT) and occupational therapy (OT) evaluative procedures. The new code descriptions for PT and OT evaluative procedures include specific components that are required for reporting, and the corresponding typical face-to-face times for each service.
Six of the new codes are evaluation codes that replace the PT (97001) and OT (97003) evaluation codes. The new codes are based on patient complexity and the level of clinical decision making: low, moderate, and high. The 3 new PT evaluative procedure codes, descriptions, and required corresponding therapy modifier are listed in Table 1, and the 3 new OT evaluative procedure codes, descriptions, and required OT therapy modifier are listed in Table 2.
Two of the new codes are reevaluation codes that replace the PT (97002) and OT (97004) reevaluation codes. The new codes are reported for an established patient when a revised plan of care is indicated. Reevaluation may be indicated more than once during a plan of care. See Table 3 for the PT and OT reevaluation codes, descriptions, and required therapy modifier.
Similar to their predecessor codes, the 8 new codes are designated as "always therapy" codes and must be reported with the appropriate therapy modifier, GP or GO, to indicate that the services are furnished under a PT or OT plan of care, respectively (http://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html).
The following are some PT evaluation definitions that are pertinent to the new codes:
* General condition: Assesses ability to communicate needs, consciousness, orientation to persons/place/time, anticipated emotional and behavioral responses, and learning preferences
* Body systems: Musculoskeletal, neuromuscular, cardiovascular, pulmonary, and integumentary
* Body structures: Structural or anatomical parts of the body systems, such as organs, limbs, and their components, classified according to body systems
* Body regions: Head, neck, back, lower and upper extremities, and trunk
* Review of musculoskeletal system: Assesses gross symmetry, gross range of motion, gross strength, and the patient's height and weight
* Review of cardiovascular pulmonary system: Assesses the patient's heart rate, respiratory rate, blood pressure, and edema
* Review of neuromuscular system: Assesses gross coordinated movement such as balance, gait, locomotion, transfers, and transitions and assesses motor function such as motor control and motor learning
* Review of integumentary system: Assesses pliability (texture), skin color, skin integrity, and presence of scars
The following are some OT evaluation definitions that are pertinent to the new codes:
* Review of physical skills: Reviews impairment of body structure or body function, such as balance, mobility, strength, endurance, fine or gross motor coordination, sensation, or dexterity
* Review of cognitive skills: Reviews patient's ability to attend, perceive, think, understand, problem solve, mentally sequence, learn, and remember, which results in the ability to organize occupational performance in a timely and safe manner
* Review of psychosocial skills: Reviews interpersonal interactions, habits, routines and behaviors; active use of coping strategies; and adaptation to environment to successfully and appropriately participate in everyday tasks and social situations
Since these new codes were released, these are the most frequently asked questions that this author has received:
Q: Are the 8 new therapy evaluation codes recognized in all sites of care?
A: Yes, the therapy services can be performed, and the new evaluation codes can be used in multiple places of service
Q: What are the required components of the new therapy evaluation codes?
A: The new PT evaluation service codes require history, examination, clinical decision making, and development of plan of care. The new OT evaluation service codes require occupational profile and patient history (medical and therapy), assessment of occupational performance, clinical decision making, and development of plan of care.
Q: Is it appropriate to report the reevaluation if the patient's status changes and the reevaluation is medically reasonable and necessary?
A: Yes. Therapists may need to append modifier 59, if performing 97164/97168 with other 97000 series codes. Contact specific payers to determine their guidance about this circumstance.
Q: Can a therapeutic procedure be reported on the same day as an evaluation or reevaluation?
A: Yes, when the medical record documentation supports the medical necessity of both services, they both may be reported. However, some payer policies may not pay for them both on the same day. Be sure to check medical policies, national correct coding initiative edits, and so on.
Q: Will all payers recognize the new evaluation codes?
A: All Medicare payers should recognize the new codes. During insurance benefit verification, check if commercial payers, worker's compensation, and auto liability, for example, recognize the new codes.
Q: Do the new therapy evaluation codes track to an ambulatory payment classification group in the outpatient prospective payment system?
A: No. Like all other "always therapy" codes, the new therapy evaluation codes are paid via the Medicare Physician Fee Schedule. See Table 4 for a comparison of the old versus the new therapy evaluation codes Medicare national average allowable rates.
Q: Since it makes no sense that the Medicare national average allowable rates for the low, moderate, and high PT and OT evaluation services are identical, should PTs and OTs set their charges to appropriately represent the different levels of care?
A: Hopefully, in the future, the Centers for Medicare & Medicaid Services (CMS) will adopt a tiered payment system for the new evaluation services. Therefore, PTs and OTs should carefully report the code that most accurately describes the level of evaluation performed and should establish a charge that appropriately represents each level of evaluation. The CMS will most likely collect and analyze this utilization data for possible future payment policy refinements. Therefore, therapists should not take shortcuts and report only 1 code with 1 charge.
*CPT is a registered trademark of the American Medical Association. [Context Link]