New Evaluation and Re-Evaluation Codes Are Coming in 2017

13 Oct 2016

Drastic changes are coming to evaluation and re-evaluation codes for physical and occupational therapy in 2017.  As of January 1st, 2017, the current evaluation and re-evaluation codes (97001, 97002, 97003, and 97004) will be removed from the CPT code list and replaced with three new evaluation codes for both PT and OT along with one new re-evaluation code for each discipline.  All HIPAA covered entities must use the current year’s CPT codes which means Medicare and most commercial insurances will be required to switch to the new codes on January 1st.  Workers comp carriers and auto insurance carriers are not mandated by HIPAA to use the CPT codes and could therefore still use the old eval and re-eval codes.

The new evaluation codes will include different components of complexity and severity.  For physical therapy, those components include:

  • Patient history (medical and functional, including relevant comorbidities & personal factors)
  • Examination AND the use of standardized tests and measures
  • Clinical presentation of the patient
  • Clinical decision making (including the use of a standardized patient assessment instrument and/or measurable assessment of functional outcome)

The new evaluation codes for physical therapy are:

capture-pt

For occupational therapy, the components of complexity and severity are:

  • Occupational profile and medical/therapy history
  • Assessment of performance deficits
  • Clinical decision making

The new occupational therapy codes along with their descriptors are:

capture-ot

As mentioned earlier, there will also be new re-evaluation codes for each discipline.  For PT, the new re-evaluation code is 97164 (Reevaluation of physical therapy established plan of care) and will require these components:

  • An examination including a review of history and use of standardized tests and measures; and
  • Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome

For OT, the new re-evaluation code is 97168 (Reevaluation of occupational therapy established plan of care) and will require these components:

  • An assessment of changes in patient functional or medical status with revised plan of care;
  • An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and
  • A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.

Future blog posts will provide a deeper dive into defining the parameters outlined above as well as additional information regarding the selection criteria for the different evaluation codes. Stay tuned.