Physical therapists (PTs) have an integral role in helping to diagnose and treat many common ailments and musculoskeletal disorders, and in providing postoperative care to patients who undergo hip and knee replacement surgery. PTs are set to see coding changes in 2017 which recognize varying levels of complexity in evaluations, though there is no difference in payment rates among these levels and no changes from the current rates. The aim of the new three-tiered system of CPT evaluation codes developed by the American Physical Therapy Association (APTA) and its partners is part of the drive towards creating a physical therapy medical billing system that fairly reflects the proficiency, skill, and responsibility of PTs in caring for their patients.
In addition to three new PT evaluation codes, there is one new PT re-evaluation code. The CMS proposed physician fee schedule for 2017 is a value-based payment system which allows for the different levels of evaluation complexity performed by therapists:
- Low-complexity (97161)
- Moderate-complexity (97162)
- High-complexity (97163)
The new reevaluation code replaces the current 97002.
| New PT CPT codes | CPT long form descriptors for physical medicine and rehabilitation | Time spent face-to-face with the patient and/or family |
| 97161 | Low complexity PT evaluation, requiring the following components: – history with no personal factors and/or comorbidities that impact the plan of care – Exam 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 – A clinical presentation with stable and/or uncomplicated characteristics – Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. |
Typically 20 minutes |
| 97163 | Moderate complexity evaluation requiring the following components: – history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care – exam 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 evolving clinical presentation with changing characteristics – Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. |
Typically 30 minutes |
| 97163 | High complexity evaluation requiring the following components: – history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care – exam 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 – a clinical presentation with unstable and unpredictable characteristics – clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. |
Typically 45 minutes |
| 97164 | Reevaluation of PT established plan of care, requiring the following components: – Exam including a review of history and use of standardized tests and measures is required – Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome |
Typically 20 minutes |
The Centers for Medicare and Medicaid (CMS) has recommended that PTs learn how to appropriately use the new physical therapy medical billing and coding system so that they can provide better care as well as get reimbursed appropriately. According to APTA, therapists will need to learn how to “differentiate the number of personal factors that actually affect the plan of care and how to select the number of elements from any of the body structures and functions, activity limitations, and participation restrictions to make sure there is no duplication during the PT’s examination of body systems”. Partnering with a reliable physical therapy medical coding company can make staying ahead of these industry changes much easier.
Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.