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New Physical Therapy Codes for 2017

July 8, 2016 8 Comments

New physical therapy codes for 2017 were released yesterday by tricycle-691587_1280CMS as part of the Medicare Physician Fee Schedule Proposed Rule for 2017 (CMS-1654-P).  The therapy community has long awaiting the anticipated changes to the current CPT coding structure.  The proposed rule provides information on the new physical therapy and occupational therapy evaluation codes (we will cover occupational therapy codes in the next post).

There are 3 new physical therapy evaluation codes and 1 new physical therapy re-evaluation code.  The codes are based in large part on the amount of time and complexity involved in the evaluation.   The table below identifies the new physical therapy codes for 2017 and give the long form description of the code.

New Physical Therapy Codes for 2017

New Physical Therapy CPT CodeCPT Long Form Descriptors for Physical Medicine and Rehabilitation
97X61Physical therapy evaluation: low complexity, requiring these components:
● A history with no personal factors and/or comorbidities that impact the plan of care;
● 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;
● A clinical presentation with stable and/or uncomplicated characteristics; and
● Clinical decision making of low complexity using standardized patient assessment instrument and/or
measurable assessment of functional outcome.
Typically, 20 minutes are spent face-to-face with the patient and/or family.
97X62Physical therapy evaluation: moderate complexity, requiring these components:
● A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of
care;
● 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 evolving clinical presentation with changing characteristics; and
● Clinical decision making of moderate complexity using standardized patient assessment instrument
and/or measurable assessment of functional outcome.
Typically, 30 minutes are spent face-to-face with the patient and/or family.
97X63Physical therapy evaluation: high complexity, requiring these components:
● A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care;
● 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;
● A clinical presentation with unstable and unpredictable characteristics; and
● Clinical decision making of high complexity using standardized patient assessment instrument and/or
measurable assessment of functional outcome.
Typically, 45 minutes are spent face-to-face with the patient and/or family.
97X64Reevaluation of physical therapy established plan of care, requiring these components:
● An examination including a review of history and use of standardized tests and measures is required;
and
● Revised plan of care using a standardized patient assessment instrument and/or measurable assessment
of functional outcome
Typically, 20 minutes are spent face-to-face with the patient and/or family.
97X65 Occupational therapy evaluation, low complexity, requiring these components:

According to CMS, the CPT Editorial Panel’s creation of the new PT and OT evaluative procedures codes grew out of a CPT workgroup originally convened in January 2012  at a time when CMS was contemplating major revision of the Physical Medicine and Rehabilitation CPT section of codes.  This was in response to CMS identifying therapy codes as potentially “misvalued” codes, including CPT code 97001 and the other PT/OT evaluative codes in the CY 2012 PFS proposed rule.

Stay tuned to this blog for continued updates on the new physical therapy codes for 2017 as well as the new occupational therapy codes for 2017.

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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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Comments (8)

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  1. Laura says:

    Thank you Nancy, are these codes exclusively for Part B therapy services?

  2. Henry M Castillo says:

    Hi,

    Is there an audit tool that we can use for decision making just like on E&M.

    thanks

  3. Hi Laura – Thank you for your question. These codes have been determined by CMS to be “always therapy codes” so in other words that must be accompanied by a therapy modifier (-GP or -GO).

  4. Andrea says:

    Nancy,
    Will the new codes require completion and documentation of a standardized tool (such as LEFS or quick dash) or do standardized tests and measures full fill statement for using an assessment in long descriptor… “Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.”
    Thank you!

  5. Brenda Verhey says:

    Nancy, I attended the webinar re: the New PT and OT codes yesterday, and Pediatric patients were not mentioned. Do these same codes apply the Pediatric patients in out OP Rehabilitation settings?

  6. Brenda, the new codes apply for all therapy services billed and paid under the Medicare Physician Fee Schedule (MPFS). For outpatient pediatrics these codes will apply. Hospitals may chose to use the new codes to describe inpatient therapy services, but inpatient hospital therapy is not paid under the MPFS.

  7. Nicole Clark says:

    Do you anticipate any scenarios where the complexity of a PT evaluation would vary from the complexity of an OT evaluation? For example, the OT scored the eval as low complexity and the PT as high based on each discipline’s involvement.
    Thank you!

  8. Nicole – Thank you for your comment. Indeed, this scenario can take place. The criteria for the evaluation are different for PT and OT, and the guidance for each (contained in the CPT) must be followed. Additionally great resources are available at the APTA and AOTA website, including introductory webinars by each association. In some live seminars that I have done, I can for sure tell you that even PTs evaluate the SAME patient differently, as well as OTs. I recently had a scenario wherein PT and OT CHTs evaluated patients differently for a variety of reasons. We did case study presentations (all from same hand therapy clinic) and it was instructive to see the different presentations and lively discussion. These type of activities assist therapists in vetting the elements of a code. I hope this was helpful.

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