Using the New Evaluation and Re-Evaluation Codes for Physical Therapy and Occupational Therapy

Replacement Physical Therapy CPT Codes for 97001

Physical therapists will no longer use the same evaluation code for every patient. Instead, they will choose from a set of three different evaluative codes that are tiered according to complexity. The physical therapy codes to be used with your physical therapy software are:

97161
Physical therapy evaluation: low complexity

97162
Physical therapy evaluation: moderate complexity

97163
Physical therapy evaluation: high complexity

New modifiers and CPT codes for Physical Therapy evaluations

Replacement Physical Therapy CPT Codes for 97003

Occupational therapists also must select from a new set of three tiered OT evaluation codes when billing for patient evaluations. And like the new PT codes, these codes are organized by complexity. The occupational therapy codes to be used with your occupational therapy software are:

97165
Occupational therapy evaluation: low complexity

97166
Occupational therapy evaluation: moderate complexity

97167
Occupational therapy evaluation: high complexity

New modifiers and Occupational Therapy CPT codes for evaluations

Replacement Occupational Therapy CPT Codes for 97002 and 97004

This update also affects what get entered in your therapy documentation software for PT and OT re-evaluations. However, unlike the PT and OT evaluation codes, the re-evaluation codes are not tiered according to complexity. Instead, there is one replacement code for 97002 and one for 97004, as shown below.

97164
Re-evaluation of physical therapy established plan of care requiring:

• An examination (including a review of history and use of standardized tests and measures)
• A revised plan of care (based on use of a standardized patient assessment instrument and/or measurable assessment of functional outcome)

97168
Re-evaluation of occupational therapy established plan of care requiring:

• An assessment of changes in patient functional or medical status, along with a 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
• A revised plan of care (a formal re-evaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required)

Selecting the Right Level of Evaluation Complexity

Now, the big question for any therapy professional affected by these coding updates is: how does one go about selecting the appropriate level of complexity for each patient’s therapy evaluation? Here are the four main evaluation complexity factors, along with a few sub-factors:

• Patient history
  • Personal factors
    • Patient age
    • Education level
    • Coping style
    • Social background
    • Lifestyle
    • Character
    • Attitudes
• Comorbidities
  • Past medical history (examples below):
    • Obesity
    • Diabetes
    • Hearing loss
    • Visual deficits
    • Cognitive deficits
• Depth and results of examination and use of standardized tests and measures
  • Expected progression
  • Objective findings
• Clinical presentation
  • Status of current condition
  • Mechanism of current condition
• Clinical decision-making
  • Goal establishment
  • Prognosis and probable outcome

Vocabulary

Prior to discussing the defining characteristics of each complexity level, let’s define a few terms that will pop up throughout this post:

• Body Regions: Refers to areas of the body, such as head, neck, back, lower extremities, upper extremities, and trunk.
• Body Systems: Includes the circulatory, skeletal, muscular, nervous, respiratory, immune, excretory, integumentary, lymphatic, cardiovascular, reproductive, and digestive systems.
• Body Structures: Refers to the body’s structural or anatomical parts (e.g., organs or limbs), which are classified according to body systems.
• Body Functions: Refers to physiological functions of body systems.

Characteristics of a Low-Complexity Evaluation

PT (97161)

Duration
Typically, the PT spends 20 minutes face-to-face with the patient and/or family.

History
The patient has a history of the present problem without any personal factors and/or comorbidities that impact the plan of care.

Examination
The PT completes 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 Presentation
The clinical presentation is stable and/or uncomplicated.

Decision-Making
The PT exercises clinical decision-making of low complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

OT (97165)

Duration
Typically, the OT spends 30 minutes face-to-face with the patient and/or family.

History
The patient’s occupational profile and medical and therapy history includes a brief history with review of medical and/or therapy records related to the presenting problem.

Examination
The OT completes an assessment(s) identifying 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.

Decision-Making
The OT exercises 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. The 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.

Characteristics of a Moderate-Complexity Evaluation

PT (97162)

Duration
Typically, the PT spends 30 minutes face-to-face with the patient and/or family.

History
The patient has a history of the present problem with a history of 1-2 personal factors and/or comorbidities that impact the plan of care.

Examination
The PT completes an examination of body systems using standardized tests and measures addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.

Clinical Presentation
The clinical presentation is evolving with changing characteristics.

Decision-Making
The PT exercises clinical decision-making of a moderate complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

OT (97166)

Duration
Typically, the OT spends 45 minutes face-to-face with the patient and/or family.

History
The patient’s occupational profile and medical and therapy history includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.

Examination
The OT completes an assessment(s) identifying 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.

Decision-Making
The OT exercises clinical decision-making of a moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. The 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 completion of evaluation component.

Characteristics of a High-Complexity Evaluation

PT (97163)

Duration
Typically, the PT spends 45 minutes face-to-face with the patient and/or family.

History
The patient has a history of the present problem with 3 or more personal factors and/or comorbidities that impact the plan of care.

Examination
The PT completes 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.

Clinical Presentation
The clinical presentation is unstable with unpredictable characteristics.

Decision-Making
The PT exercises clinical decision-making of a high complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

OT (97167)

Duration
Typically, the OT spends 60 minutes face-to-face with the patient and/or family.

History
The patient’s occupational profile and medical and therapy history includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance.

Examination
The OT completes an assessment(s) identifying 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.

Decision-Making
The OT exercises clinical decision-making of a high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. The 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 completion of evaluation component.

Adding/Removing CPT codes with ClinicSource

Using your ClinicSource software, Occupational Therapy CPT codes for physical therapy can be added and removed as needed from your clinic to meet the needs of your business.

To add/remove Occupational Therapy CPT codes, navigate to Setup>CPT Codes and select the discipline you wish to work with from the top drop-down selection tool in the header. In the list in the main window, you can select the code you wish to remove by checking the box in the far left column and then the wastebasket icon in the header. To add codes to your clinic, select the discipline(s) in the top left box, type in the CPT code and provide yourself a description and select the add button.

*Remember, medical necessity plays a major role in code selection, and your therapy documentation should always clearly support your coding choices. Always follow the rules and guides set forth by the payer when using any of the above codes.

Hundreds of OT and PT Evaluation Templates Available with ClinicSource

When it comes to occupational therapy evaluation templates and physical therapy evaluation templates, ClinicSource has you covered. No matter what complexity or level any patient may be, you’ll easily find the perfect template for any situation. This customizable platform intuitively offers options relevant to your session type, saving you time and making your therapy documentation much easier to handle.

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