Harmony Healthcare Blog

Decoding the CPT Codes: Physical Therapy and Occupational Therapy Evaluation (Part 2)

Posted by Melissa Fox on Tue, Dec 27, 2016


Edited by Kris Mastrangelo

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency


therapy_woman.jpgTherapy Providers seek clinical guidance on how to define the new CPT Codes for Occupational Therapy and Physical Therapy evaluations.  The guidelines indicate that the Clinician must consider: 

  • the presenting problem(s)
  • the reason(s) for referral
  • and the patient’s goals 

as a determining factor in which code will be selected.  (Missed Part 1? You can read Part 1 of the CPT Code series by clicking here.)

Foundation of PT and OT Evaluation CPT Codes 

Description of Evaluation

PT CPT for Code

Typical Time billed

OT CPT Code for Evaluation

Typical Time billed

Low Complexity

CPT 97161

20 minutes

CPT 97165

30 minutes

Moderate Complexity

CPT 97162

30 minutes

CPT 97166

45 minutes

High Complexity

CPT 97163

45 minutes

CPT 97167

60 minutes


Comparison of Correct Level of Evaluation

Description of Level of Evaluation

PT Levels of Evaluation

OT Levels of Evaluation

Level 1:

History

Occupational Profile and client history (medical and therapy)

Level 2:

Examination of body systems

Assessments of occupational performance

Level 3:

Clinical Presentation

Clinical Decision Making

Level 4:

Clinical Decision Making (complexity)

Development of Care Plan


The following tables elaborate on the details and tier for each of the levels outlined above.

Comparison of Level 1: History

Tiers

PT: History

OT: Occupational Profile and client history (medical and therapy)

Low Complexity

No personal factors and or comorbidities

Brief history including review of medical and or therapy relating to the presenting problem.

Moderate Complexity

1-2 personal factors and /or comorbidities

Expanded review of medical and or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.

High Complexity

3 or more personal factors and or comorbidities

Extensive additional review of physical, cognitive, or psychosocial history related to current functional performance.

Jimmo and Improvement Standard

Comparison of Level 2: Functional component deficits

Tiers

PT: Examination of body systems

OT: Assessments of occupational performance

Low Complexity

Addressing 1-2 elements

Assessment identifies 1-3 performance deficits including physical, cognitive, and psychosocial

Moderate Complexity

Addressing a total of 3 or more elements

Assessment identifies 3-5 performance deficits including physical, cognitive, and psychosocial

High Complexity

Addressing a total of 4 or more elements

Assessment identifies 5 or more performance deficits including physical, cognitive, and psychosocial 


Comparison of Level 3: Clinical findings
 

Tiers

PT: Clinical Presentation

OT: Clinical Decision Making

Low Complexity

Stable

Analysis of data from problem focused assessment

Moderate Complexity

Evolving

Analysis of data from detailed assessment

High Complexity

Unstable

Analysis of data from comprehensive assessment 


Comparison of Level 4: Clinical justification and skilled interventions

Tiers

PT: Clinical Decision Making (complexity)

OT: Development of Care Plan

Low Complexity

Low

Limited number of treatment options

Moderate Complexity

Moderate

Several treatment options

High Complexity

High

Multiple treatment options

 

The Physical Therapy and Occupational Therapy plan of care is developed following the analysis of all information that is gathered from the client’s history including medical, therapy and prior level of function which is based on patient functional and cognitive performance. Harmony Healthcare International (HHI) encourages therapy providers to investigate utilization of standardized assessment tools to support patient centered analysis and delivery of a low, moderate or high complexity treatment plan.

If you have questions about the new CPT Codes, please contact Harmony Healthcare by clicking here or calling our office at (800) 530-4413.
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Tags: CPT Codes

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