Questions & Answers on the New Physical Therapy and Occupational Therapy Evaluation Codes

December 26, 2016
Comments off

QUESTION: What are the new physical therapy evaluation codes?

ANSWER: 97161 for a low complexity initial evaluation, 97162 for a moderate complexity initial evaluation, 97163 for a high complexity initial evaluation and 97164 for a re-evaluation.

QUESTION: What are the new Occupational Therapy evaluation codes?

ANSWER: 97165 for a low complexity initial evaluation, 97166 for a moderate complexity initial evaluation, 97167 for a high complexity initial evaluation and 97168 for a re-evaluation.

QUESTION: What are the sources used for determining a performance deficit for the OT evaluation? Could you provide a list of examples?

ANSWER: Performance deficits are defined in the CPT Manual Introductory Language. They are defined as:

Performance Deficits: Inability to complete activities due to the lack of skills in one or more of the categories below:

Physical Skills: Impairments of body structure or body function (e.g., balance, mobility, strength, endurance, fine or gross motor coordination, sensation, dexterity).

Cognitive Skills: Ability to attend, perceive, think, understand, problem solve, mentally sequence, learn, and remember resulting in the ability to organize occupational performance in a timely and safe manner. These skills are observed when:

(1) a person attend to /selects, interacts with, uses task tools and materials;
(2) carries out individual actions and steps; and
(3) modifies performance when problems are encountered.

Psychosocial Skills: Interpersonal interactions, habits, routines and behaviors, active use of coping strategies, and/or environmental adaptations to develop skills necessary to successfully and appropriately participate in everyday tasks and social situations.

It is also based on the OT Framework. Though they do not specifically define performance deficits, you can still correlate performance skills from the Framework. Reviewing the OT Framework can help you understand these new concepts.

QUESTION: What is the difference between evolving and changing presentation to unstable and unpredictable? Because these are being measured at first visit, how would you know this? Just from history?

ANSWER: Clinical presentation involves patient specific characteristics, their physiological responses and symptoms, such as pain, swelling, BP, pulse, sweating, or neurological signs.

To determine if the patient’s presentation is evolving or unpredictable, the clinician should take into consideration characteristics such as fluctuation in pain, results from patient reported outcomes and functional tests, response to activity/prior treatment, frequent acute episodes with unpredictable responses or resolving pain/swelling/symptoms and unstable medical conditions. An evolving presentation is one where the symptoms are still progressing, such as back pain that is progressively radiating down a lower extremity, a TIA/CVA that may not yet be stable and neurological signs are still progressing. An unstable and unpredictable presentation is a medical condition that can present differently during the evaluation and its presentation is not following the expected course, e.g., unstable blood pressure not controlled by medication; unstable diabetes could be another example. Information provided by the patient on a questionnaire can provide insight; however, the therapist will need to inquire about this area and supplement with testing.

QUESTION: Do we still need to document total time spent with the patient for evaluations?

ANSWER: Medicare continues to require that documentation include total timed code treatment minutes and total treatment time in minutes. Total treatment time includes the minutes for timed code treatment and untimed code treatment. Evaluation minutes are untimed and are included as part of total treatment minutes.

QUESTION: If there are any examples specific to home health pediatrics, that would be very helpful. Seems like most of what I have seen has been related to Medicare, PM&R, etc., but we are assuming this applies to our pediatric home health therapy services too.

ANSWER: The new codes apply to all outpatient settings that currently utilize the 97001, 97002, 97003 and 97004 codes for evaluations and re-evaluations. These codes are all being replaced by the new tiered codes. In home health, they apply only to claims with a bill type 34x.
See the following links for additional guidance regarding home health billing and outpatient therapy:

QUESTION: At times, an evaluation is charged and the documentation states that “formal measurements” will be taken next session. Can an evaluation be charged for that visit?

ANSWER: The evaluation establishes the patient’s plan of care and the need for therapy services. If the patient cannot participate in the completion of standardized tests and measures at the time of evaluation, the reason for that should be documented. They should not be excluded for the convenience of the therapist. Also, while standardized tests and measures can (and should be) used throughout the patient’s episode of care to help determine if the patient is making progress, only one initial evaluation can be charged for an episode of care. If there is a medical reason why a patient cannot tolerate participation in standardized tests during the initial evaluation, perhaps that relates to the complexity of the patient.

QUESTION: Can we bill treatment codes in addition to the evaluation code on the same day of service?

ANSWER: Yes, as long as you have a physician order that is broad enough to cover not only the evaluation, but also any treatment provided (e.g., order to “eval and treat”). The documentation will also need to support the services provided as treatment being distinct and separate from the evaluation. This practice is not changing and will be the same as for the current evaluation codes.

QUESTION: In regards to OT identification of performance deficits, what level of specificity is used? For example, motor coordination deficit or is it broken into gross motor, fine motor, visual motor, etc.?

ANSWER: The CPT code definitions do not break down the specifics of motor coordination deficits in counting factors, but this does not mean that all areas should not be assessed as appropriate for the patient needs.

QUESTION: When you refer to activity limitations within an examination, are you referring to FIM scores, etc. or is it more of a history/functional outcome score that already has listed the activities and participation limitations?

ANSWER: An activity is the execution of a task or action by an individual, such as being able to walk upstairs, dress oneself, etc. Activities cover a wide range of areas, such as mobility, self-care, domestic life, interpersonal relationships/interactions, community, social and civic life and other major life areas. Activity limitation is difficulty executing these tasks and actions and the extent of that difficulty could be described with a standardized measure such as a FIM score or score on other standardized tests or measures.

QUESTION: We currently take work requirements and activity limitations in history. Do we simply place these in a different section to qualify?

ANSWER: If the information is available, documented and accessible within your evaluation to support your choice of evaluation code, you do not need to place the information in a specific section.

QUESTION: Our understanding is that a patient can only have one evaluation in a year per discipline for a condition. Based on what you just said, even if the patient comes back after three months for the same condition we would do a whole new evaluation, but possibly a lower code this time because we do not need to do such an extensive history and exam?

ANSWER: While some insurance plans may refuse to pay for a second evaluation for the same condition, a second evaluation would still need to be done because the patient was not under an active plan of care. The second evaluation may or may not be at a lower code depending on all the factors relating to the patient’s history and condition. Just because you are familiar with the patient’s history does not negate contributing factors that could impact the complexity of the evaluation.

QUESTION: What is the difference in performance skills and performance deficits in relation to documentation? Can you give me an example?

ANSWER: Performance skills are the physical, cognitive and psychosocial actions and capabilities that a person must have to allow him to participate in the activities within his surroundings, such as the strength, endurance and problem solving skills to be able to dress each day and go to work, or to be able to take care of another individual. If there is a problem executing one of these skills due to, e.g., weakness or confusion, that will result in a performance deficit of being unable to perform the task. Reviewing the AOTA Practice Framework will provide a good basis for these concepts.

QUESTION: In the patient assessment portion of the OT initial evaluation, what if a patient cannot engage in a standardized test due to severe physical or mental limitations? Do we still need to do a standardized test?

ANSWER: When possible and available, a standardized, objective measure should be used. Granted, there will be times when a patient is not able to effectively participate in a standardized test and the reason for that should be documented. The long descriptors for each OT evaluation code do use the term assessment, rather than specifically stating just standardized tests and measures, which allows both standardized and non-standardized assessments to meet this criterion.

QUESTION: For a severely involved pediatric patient over 10, do you have a suggestion for an appropriate standardized test or functional outcome based tool for OT and PT?

ANSWER: The therapist needs to choose the standardized test and functional outcome tools based on the patient type and practice. The APTA Guide to PT Practice has a list of available tests and measures used by PT that could be a starting point. OT can use many of these tools and the AOTA also has recommendations that can be accessed using the attached link:

QUESTION: Will the new codes apply to inpatients who are under observation?

ANSWER: Patients in an observation stay are by definition outpatients, so these new codes would apply to those patients.

QUESTION: Our hospital had already decided to bill the three initial evaluation levels at different rates based on complexity guidelines even if payment is the same from CMS for all three. Is this acceptable or should our facility charge the same for all three?

ANSWER: You can have different charges. Also, non-Medicare payers will likely pay different amounts depending on the evaluation level, so charges should be different.

QUESTION: Can range of motion testing by using a goniometer and grip strength testing using a dynamometer be considered standardized tests?

ANSWER: Yes, if they are applicable to the deficits that the patient presents and deficits in those areas are being addressed in the treatment plan.

QUESTION: Would choosing the wrong code be a reason for a payment denial?

ANSWER: For 2017, Medicare is not making any changes to its Benefit Policy Manual related to documentation requirements for evaluations and reviewers will not be allowed to deny services based on the wrong choice of evaluation code. In physician evaluation and management coding, which is a similar acuity-based system, the Medicare MACs and RACs routinely review physician documentation to determine if it supports the code level billed. If it does not, the payment is adjusted to the lower code. Once CMS applies different payment amounts to the different therapy evaluation levels, we anticipate a similar review and payment adjustments to occur.

Keep in mind that non-Medicare payers will likely pay different amounts in 2017 depending on the evaluation level, so they may deny or reduce payments if they determine that the evaluation should have been coded at a lower level.

QUESTION: Is there an available list of recognized standardized tests and measures? Some methodologies of practice (e.g., Postural Restoration Institute) have tests and measures that may not be included in a traditional PT list.

ANSWER: There is not an official list of tests and measures that should be used. Rehab Measures and the PT Practice Guide are two good resources.

QUESTION: Can we use a self-report questionnaire, such as DASH? Would that be sufficient for the assessment portion or do we need to use tests that provide standardized numbers?

ANSWER: The DASH is a great outcome measure and can be used with other standardized tests and measures per the deficits that the patient exhibits.

QUESTION: Are we able to bill 96111 in addition to these new PT evaluation codes? If not, what should we bill for standardized testing?

ANSWER: Yes, you can still bill 96111 for developmental testing, extended. Just ensure that you still follow any CCI edits that apply for services provided on the same date.

QUESTION: We have read that there is a 1/1/17 effective date, but a 4/3/17 implementation date. Can you please explain what will occur on 4/3?

ANSWER: We are not aware of any delay in implementation until 4/3/17, or otherwise. You should start using the new codes for DOS on and after 1/1/17.

QUESTION: From whom can we expect to receive feedback regarding the appropriateness of the codes we use in 2017? From commercial insurance carriers? From Medicaid?

ANSWER: Commercial insurers may set up rules for usage that are different from Medicare. We do not expect any feedback from Medicare regarding the appropriateness of codes until the point at which payment is different by evaluation level, and then that feedback will come based on audits that the MACs and RACs perform. Medicaid is state-specific, so review and payment practices will differ by state. The APTA and AOTA should publish additional information and guidance as full usage of these new codes is implemented. Also, private consulting firms will be offering evaluation documentation and coding review to provide feedback to outpatient practices.

QUESTION: Pediatric standardized assessments generally require 45-60 minutes to administer and these are required by most payers. Will there be any consideration for the types of tests that are used in different settings as related to the complexity of the evaluation?

ANSWER: They may correlate in some cases, but if you use “X” test, you do not automatically code as a high or low complexity evaluation because many other factors play into determining the appropriate evaluation code.

QUESTION: Will the complexity level affect or limit the number of patient visits?

ANSWER: No. The complexity of the evaluation does not impact the number of patient visits, although there may be a correlation. The frequency and duration of the treatment to be provided is a component of the clinician-specific decision that impacts the development of the patient-specific plan of care. For example, a patient with a very complex presentation may require a high complexity evaluation; however, due to the patient’s prognosis, the intervention may be focused on staff or family training and may be of low frequency and duration.

QUESTION: I was practicing an evaluation to determine which code should be used. There was one medical history factor, three examination factors, but no evolving or changing clinical characteristics. It was low to moderate complexity to me. What code do I use?

ANSWER: The components for this code fall more within the low category as the patient presentation appears stable with a straight forward assessment. If you still feel moderate complexity, may be what is most appropriate, you should look at the case more closely … did you miss a factor that would change that patient’s overall presentation? Why did you feel that it was moderate complexity? Was it because it took you a lot of time or was the clinical decision making involved that much more complex than your routine approach for that patient presentation? Remember that you ultimately make the choice, but you must justify and support your choice with the documentation.

QUESTION: Some of these categories are not as easily applied to pediatrics. Is there any guidance that is available for the pediatric population?

ANSWER: The CPT manual does not provide any additional guidance regarding these codes specific to any patient population. We recommend that you contact the pediatric specialty sections within the APTA and AOTA.

QUESTION: For Medicare patients, are we still required to report the G codes?

ANSWER: Yes. The G-codes are separate and distinct from the evaluation codes and G-code reporting continues as usual.

QUESTION: We use G-codes for home health PPS billing. Will these codes change to match/reflect the new evaluation codes or are the new evaluation codes only for outpatient/hospital billing?

ANSWER: The G codes used in home health PPS (G0151, G0157 and G0159 for PT services and G0152, G0158 and G0160 for OT services) are required for bill type 32x, which is the Medicare Part A home health benefit. The new evaluation codes will be used when the patient is not covered under a home health PPS plan of care and is billed as an outpatient under bill type 34x. See the following websites for additional information regarding home health billing:

QUESTION: Do the different level complexities dictate the G codes/functional reporting measures that we report?

ANSWER: No. The evaluation codes and G-codes are two separate and distinct reporting systems and there is no direct correlation between them.

QUESTION: How frequently should a re-evaluation code be used? Is there a minimum or maximum timeframe between re-evaluations?

ANSWER: There is no requirement that the re-evaluation code be used during the course of treatment. Most state practice acts require the therapist to “reassess” the patient at periodic intervals, but this is primarily to ensure that the therapist is directing the treatment and has not delegated all care to an assistant. Many therapy providers understandably confuse state practice act requirements with coding requirements. Just because the therapist needs to see the patient every e.g., 30 days, does not mean that visit should be coded as a re-evaluation.

AMA guidance regarding evaluation and re-evaluation codes states that:
Code 97001 is intended to be used to report a physical therapy evaluation performed at the beginning of an episode of care. Code 97002 is intended to describe a reevaluation provided on subsequent date(s) of service. Reevaluations can be performed on more than one date of service during the episode of care; however, typically reevaluations should not be billed on each date of service. The intent of a reevaluation is to assess progress and modify or redirect future interventions.
CMS has issued more definitive and, in our view, stricter parameters as to when a re-evaluation should be performed. Under Medicare guidelines, a re-evaluation is medically necessary (and therefore payable) only if the therapist determines that the patient has had a significant improvement, or decline, or other change in his or her condition or functional status that was not anticipated in the POC (emphasis added).

Along these same lines, Medicare guidance regarding re-evaluations further provides that:
• Continuous assessment of the patient’s progress is a component of ongoing therapy services and is not payable as a re-evaluation.
• A re-evaluation is not a routine, recurring service, but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services.
• A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation.
• Indications for a re-evaluation include new clinical findings, a significant change in the patient’s condition, or failure to respond to the therapeutic interventions outlined in the POC.
• A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.
• A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment or terminating services.
• A re-evaluation should not be routinely required before every progress report, but may be appropriate when an assessment suggests changes not anticipated in the original POC.

Keep in mind that although these guidelines do not necessarily apply to your commercial patients, many commercial payers do basically follow Medicare guidelines to justify re-evaluations.

A re-evaluation must include a review of history and use of standardized test and measures and it is required that there is a REVISED plan of care based on the patient assessment. A re-evaluation is not based on any arbitrary measure, such as time since the initial evaluation, the end of the month, etc. It is based on an individual patient’s specific needs and may occur multiple times during an episode of care or not at all. A re-evaluation should never be done routinely at the time of a progress report or otherwise.

QUESTION: If a doctor’s order is valid for 6-months and a new doctor order is needed after 6-months (per payer policy), can you use a re-evaluation code to re-address goals/re-assess with a standardized assessment tool even if there has been no medical change, but you are revising the plan of care and re-addressing the history and clinical presentation?

ANSWER: Please see the answer immediately above. A re-evaluation is patient-specific and not driven by any specific time point, such as the end of the month or to provide a summary to a physician. Remember, if the patient was discharged and is coming back to therapy, even within a short period of time, it must be coded as an initial evaluation as there is no active plan of care.

QUESTION: What happens when the patient has a medical complication and complexity that changes midcourse in a treatment session? How will this impact initial coding and how do we approach documentation?

ANSWER: A change in patient condition does not change the initial evaluation code, because the patient presentation at the time of the evaluation determines the appropriate evaluation code. A significant change could trigger a re-evaluation and could change the treatment approach, but it would not change that initial evaluation code.

QUESTION: When we admit patients to the hospital, we sometimes see a patient and place them on caseload, but then discharge them due to a change in status. We then may receive new orders during the admission when the patient’s condition improves. We have been charging a re-evaluation as this was all during the same admission. Would we now need to charge a second evaluation because they had been discharged from PT services or should we continue to charge a re-evaluation because they never left the hospital?

ANSWER: If there is not an active plan of care in place, a re-evaluation cannot be done. If the patient was discharged and is coming back to therapy even if within a short period of time, it must be coded as an initial evaluation as there is no active plan of care. The new evaluation should justify why therapy is medically necessary for therapy at that time. There may be a new medical diagnosis code for the second evaluation that should be used, related to the reason that the patient was discharged the first time. This would further define why a new evaluation is being performed.

QUESTION: What type of therapy setting is the change in coding not going to affect?

ANSWER: The new codes apply to all outpatient settings that currently utilize the 97001, 97002, 97003 and 97004 codes for evaluations and re-evaluations. Therefore, inpatient settings such as acute inpatient, inpatient rehab facilities, LTACH as well as patients under a home health episode of care will not use these codes for billing purposes. Also, non-HIPAA entities, such as workers comp, auto liability and disability insurances, are not required to use these codes, but may choose to use them and to have different payment rates.
Each work comp and auto payer will make its own decision on its own timeline. You just need to keep an eye out for notices or proactively contact those carriers to find out their coding.

QUESTION: The presenter did mention that work comp cases and automobile cases maybe exempt. Is this applicable for work comp patients who are in any rehab setting?

ANSWER: Yes. Workers comp, auto liability and disability insurances may or may not choose to use the new codes regardless of the setting. (Also, see answer below)

QUESTION: When are they going to decide if work comp and accident cases are going to require the new coding system?

ANSWER: Each work comp and auto payer can make its own decision on its own timeline.

Very few workers comp and auto liability payers have issued any guidance as to whether they will start using the new PT/OT evaluation codes as of January 1. This obviously puts you in the awkward position of not knowing whether to submit the current pre-2017 evaluation codes (97001-97004) or the new codes for DOS on and after January 1.
Our recommendation is to have someone in your business office try to contact your provider representatives at workers compensation and auto liability payers that cover a significant portion of your patients to find out which evaluation codes they will require on and after January 1. If you do not receive confirmation that they will continue to use the current pre-2017 codes, our recommendation is to submit claims for DOS on and after January 1 using the new PT/OT evaluation codes because if your claims are denied due to the wrong set of evaluation codes, it is much easier to re-file claims that originally had the new codes with the pre-2017 evaluation codes substituted for the new codes rather than vice versa. In this way, you will already have the back-up documentation for the new different evaluation levels necessary if the payer requires the new codes.