2017 CPT® codes more accurately report and justify reimbursement for providers of physical medicine

2017 CPT® codes more accurately report and justify reimbursement for providers of physical medicine

New physical therapy (PT), occupational therapy (OT), and athletic training (AT) evaluation codes are the first significant changes to CPT® physical medicine and rehabilitation codes in two decades. The new tiered evaluation codes also introduce separate sub-heads for PT, OT, and AT evaluations, but groups them together. This will help coding and billing in clinics and facilities offering all three services.

PT is based on Clinical Decision Making. The PT codes – three evaluation and one re-evaluation-now consider:

  • Patient’s history
  • Examination results
  • Clinical decision-making
  • Development of the care plan

97161 Physical 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 form any of the following: body structures and function, 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.

OT Is Based on Occupational Performance

OTs also get a new set of codes, 97165-97168, that include:

  • Occupational profile and client history
  • Assessment of occupational performance
  • Clinical decision-making
  • Development of the care plan

OTs are keen to identify and correct performance deficits, and evaluations are meant to identify “the inability to complete activities due to the lack of skills” in one or more of these categories:

  • Physical skills such as balance, mobility, strength, endurance, motor coordination, sensation, and dexterity
  • Cognitive skills such as in interacting with tools and materials, carrying out actions, and modifying performance when encountering problems
  • Psychosocial skills such as interpersonal skills, habits, behaviors, coping strategies, and environmental adaptations

Codes 97165 and 97168 require at least 30 minutes with patient and/or family. The OT must spend as much as 45 minutes to justify reporting 97166, and 60 minutes for 97167 (the highest complexity code).

AT Is Based on Strength and Movement

AT, a growing field in physical medicine, also gets new evaluation codes. Including a patient history and examination, the 97169-97172 series — three for evaluation and one for re-evaluation — follow a similar theme to the PT evaluation codes. ATs must look at a minimum of these elements:

  • History and physical activity profile
  • Examination
  • Clinical decision-making
  • Development of the care plan

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