Harmony Healthcare Blog

New Evaluation CPT Codes

Posted by The Harmony Team on Tue, Nov 22, 2016


Edited by Kris Mastrangelo

C.A.R.E.

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


newmed.jpgCenter for Medicare and Medicaid Services (CMS) has proposed new evaluation codes for Physical and Occupational Therapy for 2017. The new codes are part of the Medicare Physician Fee Schedule Proposed Rule 2017. The new evaluation codes are stratified by complexity and time.  Changes are going to implemented on January 1, 2017.

The Current Procedural Terminology (CPT) Code 97001 for Physical Therapy Evaluation will be replaced by the following three evaluation codes:

  • 97161
    • Physical Therapy Evaluation considered low in complexity and typically includes a total of 20 minutes face to face encounter with patient and/or family.
  • 97162
    • Physical Therapy Evaluation considered moderate in complexity and typically includes a total of 30 minutes face to face encounter with patient and/or family.
  • 97163
    • Physical Therapy Evaluation considered high in complexity and typically includes a total of 45 minutes face to face encounter with patient and/or family.

The Current Procedural Terminology (CPT) Code 97003 for Occupational Therapy Evaluation will be replaced by the following three evaluation codes:

  • 97165
    • Occupational Therapy Evaluation considered low in complexity and typically includes a total of 30 minutes face to face encounter with patient and/or family.
  • 97166
    • Occupational Therapy Evaluation considered moderate in complexity and typically includes a total of 45 minutes face to face encounter with patient and/or family.
  • 97167
    • Occupational Therapy Evaluation considered high in complexity and typically includes a total of 60 minutes face to face encounter with patient and/or family.

The Physical Therapy Re-Evaluation code 97002 will be replaced with 97164.

The Occupational Therapy Re-Evaluation code 97004 will be replaced with 97168.

Physical Therapy Re-Evaluation is anticipated to typically take a total of 20 minutes, whereas Occupational Therapy Re-Evaluation is anticipated to be approximately 30 minutes in duration.
New Call-to-actionThe following four components should be considered when determining the appropriate code:

  • Patient history and co-morbidities
  • Examination and use of standardized tests/measures
  • Clinical Presentation
  • Clinical Decision Making

There are multiple factors that impact the level of the evaluation. Some of the factors include but are not limited to:  patient’s age, time since onset of illness, mechanism of injury, past medical history, past surgical history, co-morbidities, prior level of function.

Medicare pays for services based on submission of a claim using one or more CPT Codes.

CMS expressed concern about the possibility of up-coding or coding incorrectly if the various levels of evaluation were valued differently. As a result, there will be no difference in payment rendered among levels. In addition, there will be no change in the rate from the 2016.

CMS is projecting that the breakdown for the various levels of complexity will be 50% moderate, 25% low, and 25% high.

The new evaluation and reevaluation codes will apply to all insurance carriers and not just Medicare.

Please contact Harmony Healthcare International (HHI) if you would like education for your staff on the upcoming changes to the CPT codes.  Education will include how to accurately select the correct code and how to justify that selection (e.g., within their documentation).   You can contact harmony by clicking here or calling 800.530.4413.


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Tags: CPT Codes

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