Knowledge Base Article

When my son was in college, he fell and broke his leg while playing a pick-up game of basketball. Last year my elderly father fell and broke his leg. Was their rehabilitative therapy experience the same? Hardly. Was the therapist’s time, effort and consideration for the therapy evaluation the same? Hardly. A physical therapy or occupational therapy evaluation for a young, healthy teenager with no other medical conditions is not the same as a therapy evaluation for an elderly patient who has numerous other medical conditions and pre-existing limitations in functional abilities. Beginning January 2017, that fact is being addressed with new CPT codes for rehabilitative therapy evaluations based on complexity.

CMS is proposing to accept the new CPT codes for physical and occupational therapy evaluation and re-evaluation services for 2017. The new evaluation codes are tiered based on the complexity of an evaluation that may vary due to the severity and complexity of the patient’s condition. The current evaluation codes and their respective replacement codes are:

• 97001, PT evaluation will be replaced with three new codes: 97x61, 97x62, and 97x63
• New PT re-evaluation code 97x64 will replace 97002
• 97003, OT evaluation will be replaced with three new codes: 97x65, 97x66, and 97x67
• New OT re-evaluation code 97x68 will replace 97004

As discussed in the Medicare Physician Fee Schedule (MPFS) Proposed Rule , Medicare will not have tiered payments for the new codes, but will continue to make one payment amount for all three levels of evaluation. CMS states concerns about potential risk of upcoding as therapists are learning to use the new codes, the incentive to upcode differential payment rates would create, and unknown utilization of the various levels. Perhaps CMS will reconsider tiered payment rates in the future once the learning curve is past and they have some historical data on code usage. Until then payment for evaluations and re-evaluations will likely be similar to current payment rates.

CMS also identified several other therapy codes they consider to be “misvalued” that may have a negative payment rate adjustment for next year. We will have to wait on the final MPFS rule to know exact payment rates. Those CPT codes are:

• 97032 – unattended electrical stimulation,
• 97035 – ultrasound therapy,
• 97110 – therapeutic exercises,
• 97112 – neuromuscular re-education,
• 97113 – aquatic therapy/exercises,
• 97116 – gait training,
• 97140 – manual therapy,
• 97530 – therapeutic activities,
• 97535 – self care management training,
• G0283 – unattended electrical stimulation other than wound care

Therapy codes continue to be subject to the Multiple Procedure Payment Reduction (MPPR) which means only one unit of the highest paid code reported for a day of service is paid at 100%. Additional units and codes are paid at a reduced payment rate.

See Table 19 on page 350 of the MPFS proposed rule for the complete long descriptions and specific components of each new code. The PT re-evaluation code, 97x64 requires an examination with review of history, standardized tests and measures, and a revised plan of care. CPT 97x68, OT re-evaluation, also requires a revised plan of care based on assessment of the patient’s functional or medical status with an updated occupational profile. Information on the new evaluation codes is summarized in a table you can dowload by clicking here.

Therapists must educate themselves on how to appropriately use the new codes and the documentation required to support the codes. Therapists are used to scrutiny of their documentation to support the services they provide. These new tiered codes add yet another documentation challenge for therapists.