The 2 familiar CPT codes for physical therapy evaluation and reevaluation disappeared beginning January 2017. In their place, PTs must use 3 new evaluation codes and a new reevaluation code. Now is the time to become familiar with them.
The final CMS physician fee schedule for 2017 introduced the 3 new CPT codes for physical therapy evaluation and 1 new code for reevaluation. The new evaluation codes reflect 3 levels of patient presentation: low-complexity (97161), moderate-complexity (97162), and high-complexity (97163), and replace the current 97001 code. The new reevaluation code (97164) replaces the current 97002.
CMS failed to adopt tiered payment values for the 3 evaluation codes, as was recommended by the American Medical Association (AMA) Relative Update Committee. APTA's comments in response to the proposed rule had reiterated its recommendations for stratified payment for different levels of complexity in physical therapist evaluations. However, CMS held in the final rule to its original proposal for a single payment value, which did not change from the 1.20 value for the old 97001 code. CMS did adjust the value of the new code for reevaluation, raising it from 0.60 to 0.75. The agency also acknowledged APTA's concerns for adequate time to educate PTs on the use of the new coding system by making no changes to the Medicare benefits policy manual for 2017, meaning medical reviewers won't be able to penalize providers regarding the medical necessity for the new evaluation requirements.
CMS says it will collect and analyze utilization data on the new evaluation codes during 2017 for possible future changes in payment policy. What this means is that even though the code values weren’t stratified for 2017, it’s critical for PTs to be thoughtful in choosing the most accurate code for each examination, as CMS potentially will use the data when and if it does decide to establish tiered payment.
As part of APTA's longstanding efforts to pursue a new payment system that fairly reflects the expertise, skill, and responsibility of physical therapists in caring for their patients and clients, the association and its collaborators developed this 3-tiered system of CPT evaluation codes to replace the current single code that covered all physical therapist evaluations.
The new CPT evaluation and reevaluation codes are a step in the right direction toward overall payment reform, and APTA continues to work with AMA and other provider groups in seeing value-based payment evolve. For more information on APTA's efforts to reform payment, view our resources below or email firstname.lastname@example.org.