New Part B Evaluation Codes For Therapy Services In 2017
The Medicare Physician Fee Schedule Final Rule for 2017 brings new evaluation coding requirements for providers of outpatient physical and occupational therapy services under Part B.
Dan Ciolek
12/1/2016
The Medicare Physician Fee Schedule (PFS) Final Rule for Calendar Year 2017, published in the Federal Register on Nov. 15, 2016, updated Medicare Part B payment policies and rates that impact skilled nursing facility (SNF) services, including outpatient therapies. The old PT and OT evaluation and re-evaluation codes—97001-97004—are to be used for all dates of service until Dec. 31, 2016.
New Code Descriptors
Medicare Part B therapy evaluation and treatment services are paid through the reporting of procedure codes that are weighted based on work, practice expense, and malpractice relative value units (RVUs).
Effective Jan. 1, 2017, the four Common Procedural Terminology (CPT) codes used to describe PT and OT evaluations and re-evaluations (97001-97004) are being replaced by three new stratified evaluation codes (based on patient complexity), and one new re-evaluation code for each discipline (97161-97168).
The new codes will be classified as “always therapy” codes, and therefore will always have a GP or GO therapy modifier to reflect that the services were furnished under a PT or OT plan of care, respectively. The new procedure code descriptors published in the final rule are listed below.
TABLE 23—CPT LONG DESCRIPTORS FOR PHYSICAL MEDICINE AND REHABILITATION
| New CPT code
|
descriptors
|
|
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 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.
|
|
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 assessment instrument and/or measurable assessment of functional outcome.
Typically, 30 minutes are spent face-to-face with the patient and/or family.
|
|
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 assessment instrument and/or measurable assessment of functional outcome.
Typically, 45 minutes are spent face-to-face with the patient and/or family
|
|
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; 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.
|
|
97165
|
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 (i.e., 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 (e.g., 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. |
|
97166
|
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 (i.e., 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 (e.g., 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. |
|
97167
|
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 five or more performance deficits (i.e., 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 (e.g., 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.
|
|
97168
|
Re-evaluation 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.
|
New Code Values
The final rule included extensive comments pertaining to the pricing and implementation of the new PT and OT evaluation and re-evaluation codes. However, in the end, the Centers of Medicare and Medicaid Services (CMS) adopted a single value for each of the three stratified new PT and OT evaluation codes as well as retained the longstanding RVU of 1.20 that was applied to the prior 97001 and 97003 PT and OT evaluation codes. CMS did indicate that, as they collect and analyze utilization data on these new stratified codes during CY 2017, they will reconsider this topic in future rulemaking. Additionally, CMS responded favorably to comments related to the new PT and OT re-evaluation codes and increased their RVU from 0.60 on the proposed rule to 0.75 in the final rule.
Claim Audits
The American Health Care Association and other commenters indicated that these new codes represent a significant change that will require extensive provider education, changes to the CMS and Medicare Administrative Contractor (MAC) policies and training materials, as well as changes to provider billing systems.
In the final rule, CMS agreed and provided a medical review transition period for these new codes during CY 2017. CMS also delayed changes to the requirements posted in the Medicare Benefit Policy Manual (MBPM) in Chapter 15, Section 220.3 related to documentation requirements for PT and OT evaluations and re-evaluations. For more information, see Table 22 below for the manual definitions that will apply in CY 2017.
TABLE 22—FULL DEFINITIONS FOR MBPM, Chapter 15, Section 220.3
|
ThERAPY service
|
Definition
|
|
EVALUATION
|
EVALUATION is a separately payable comprehensive service provided by a clinician, as defined above, that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted, for example, for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the plan of care, including goals and the selection of interventions.
|
|
RE-EVALUATION
|
RE–EVALUATION provides additional objective information not included in other documentation. Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, or decline, or change in the patient’s condition or functional status that was not anticipated in the plan of care. Although some state regulations and state practice acts require re-evaluation at specific times, for Medicare payment, re-evaluations must also meet Medicare coverage guidelines. |
Additional Resources
Providers are encouraged to learn more about the new PT and OT evaluation codes from the following sources:
Daniel Ciolek, PT, MS, PMP, is associate vice president of therapy advocacy at the American Health Care Association. He can be reached at dciolek@ahca.org.