Starting 2017, physical therapy medical coding involves three new evaluation codes and a new reevaluation code. The evaluation codes introduced by the final CMS physician fee schedule replace code 97001 and reflect three levels of patient presentation:
- 97161 – low-complexity
- 97162 – moderate-complexity
- 97163 – high-complexity
97164 is the reevaluation code that replaced 97002.
The American Physical Therapy Association (APTA) stresses the importance of proper documentation for appropriate reimbursement when using these codes. Though there is no prescribed format for the required documentation, physical therapists (PTs) should:
- Document each required component for the reported code
- Report a lower level of complexity even if one component cannot be supported
- Ensure that the components of the documentation are clear to all third parties reading and reviewing the report of the patient’s evaluation
Accurate physical therapy medical billing and coding depends on adherence to the APTA’s guidelines on required components and supporting documentation:
- Personal factors, comorbidities: The documentation should clearly specify personal factors and comorbidities that impact patients’ participation in the plan of care, and their individual ability to progress through it. To indicate level of complexity, the number of relevant personal factors and/or comorbidities should be identified. Besides retaining a past medical history checklist and identifying comorbidities and/or personal factors in the evaluation report, it is necessary to specify the impact of these elements on the course and/or outcome of the treatment.
- Body system elements: The documentation should be clear about all body structures and functions that the physical therapist will address during treatment as well as any activity limitations/ participation restrictions that will be impacted by this intervention. Here too, stating the combined number of these structures, functions, activity limitations, and/or participation restrictions is necessary to indicate level of complexity. Standardized tests and measures need to be used to describe the examination findings.
- Clinical presentation: Documentation should have evidence of the patient’s clinical presentation, and this should be included in the assessment portion of the report. Besides evidence of the clinical presentation as stable, evolving, or unstable, other elements that could be included in the documentation are vital sign response, and description of levels of pain and cognitive performance.
- Clinical decision-making: Effective documentation of evaluation findings demonstrates clinical decision making. This includes documentation showing the number of components analyzed and examined, and which support the specific level of clinical decision making.
- Results of functional outcome tools: The documentation should mention and include the results of standardized patient assessment and functional outcomes tools used to support the physical therapist’s level of clinical decision making.
- Evaluation complexity level: The assigned level of complexity should be documented as low, moderate, or high) on the evaluation report, and also support the selected evaluation code throughout the report.
Even as PTs maintain and submit accurate documentation to support claims, there are external factors impeding reimbursement. According to a Physicians Practice report published on February 4, 2017, some insurance companies are not prepared for change in the Physical and Occupational Therapy evaluation codes. These companies could not meet the deadline of January 1, 2017 as their software systems and fee schedules were not updated to incorporate the required changes. The result is an increase in claim denials. Partnering with a reliable medical billing company is the best way for PTs identify and manage such wrongful denials. Billing and denial management specialists work with healthcare providers to dig deep into every aspect of claim denials, query payers, and correct failed claims.
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