The new PT Codes are here to stay. Starting January 1, 2017, Medicare will require Physical Therapists and Occupational Therapists to use new codes when conducting evaluations and re-evaluations of patients. We expect these new codes to be incorporated by Private insurances as well but are not certain if Workers Compensation or Auto Accidents will accept the same. Therefore, be prepared to use the new codes for Medicare and some insurances but the old codes for others.
As it relates to payment, although some of the codes require more work, time and documentation, Medicare will pay the same amount regardless of coding. As it has been in the past we expect Private Insurances to follow the same pattern. In other words, you may need to document more and work a little more for the same reimbursement.
The documentation for the codes resemble the one already used by Physicians and requires four basic components:
- Patient History
- Examination
- Clinical Presentation
- Clinical Decision Making
Time is also used as a guideline but it is simply that a guideline with little emphasis between that and the coding requirements.
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97161: Low Complexity Evaluation |
97162: Physical Therapy Evaluation–Moderate Complexity Evaluation |
97163: Physical Therapy Evaluation–High Complexity Evaluation |
97164: Re-evaluation |
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| Time | Typically, 20 minutes are spent face-to-face with the patient and/or family | Typically, 30 minutes are spent face-to-face with the patient and/or family | Typically, 45 minutes are spent face-to-face with the patient and/or family | Typically, 20 minutes are spent face-to-face with the patient and/or family |
| Patient History | A history with no personal factors and/or comorbidities that impact the plan of care | A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care | A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care | A review of history of present problem
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| Examination | 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 | An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions | 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 | An examination of body systems using standardized tests and measures
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| Clinical Presentation | A clinical presentation with stable and/or uncomplicated characteristics | An evolving clinical presentation with changing characteristics | A clinical presentation with unstable and unpredictable characteristics | |
| Clinical Decision Making | Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome | Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome | Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome | Revised plan of care using standardized patient assessment instrument and/or measurable assessment of functional outcome |
Occupational Therapists evaluation codes and guidelines have also changed and although they resemble the Physical Therapist codes they are not the same so we recommend you contact us or consult with a professional for additional guidance.
Based on the available information we recommend the following steps:
- Make sure your system can handle both coding systems;
- Check with your carriers to ensure which ones are accepting the new codes and which ones will remain the same;
- Verify that your documentation reflects the proper code.