• Compliance Matters

    Compliance Matters

    Documenting the New Evaluation Codes

    In this follow-up to the popular August 2016 PT in Motion column "The Keys to Effective Documentation,"1 we examine the essential elements payers will seek in documentation of physical therapy evaluations and reevaluations under the new CPT code set.

    Complete and accurate documentation of physical therapist services is critical to demonstrating clinical decision making, supporting medical necessity, ensuring patient safety, and justifying payment. Insufficient and improper documentation are red flags for government and private payers that may prompt further scrutiny of a provider's billing practices.

    Until January 1, 2017, physical therapists (PTs) used American Medical Association (AMA) Current Procedural Terminology (CPT) codes 97001 and 97002, respectively, for reporting evaluation and reevaluation services for payment. Those codes have been removed from the AMA manual, replaced by new code descriptors 97161, 97162, and 97163 for evaluation, and 97164 for reevaluation.

    With the launch of these new codes, payers will be looking for some key initial evaluation documentation elements. Fortunately, the overall purpose, description, and documentation of the initial evaluation and reevaluation remain the same for the new codes as was the case for the old ones.

    Basic Components

    Physical therapy evaluation continues to be a dynamic process in which the PT makes clinical judgments based on data gathered during examination. Examination includes taking a comprehensive history, performing a systems review, and conducting tests and measures. The PT evaluates examination findings, establishes a physical therapy diagnosis, determines the prognosis, and develops a plan of care that includes goals and expected outcomes, interventions to be used, and anticipated plans for ending an episode of care.

    What's different with the 3 new evaluation codes is that they are tiered to reflect the complexity of the evaluation—low, moderate, or high.

    The physical therapy reevaluation code should be reported when the PT reexamines the patient or client to evaluate progress, modify or redirect intervention, and/or revise anticipated goals and expected outcomes. Reexamination may be indicated more than once during a plan of care.

    Tests and measures should be conducted as warranted by the patient's clinical presentation. In accordance with the findings, the PT modifies the plan of care and continues to document the medical necessity of skilled intervention.

    Not unlike the former initial evaluation CPT code 97001, PTs must document, at a minimum, specific components identified in the code descriptors for the new tiered evaluation codes in order to report a particular level of physical therapy evaluation.

    Physical therapy evaluation always has included documentation of medical history, examination, clinical decision making, and development of a plan of care, so the key elements highlighted for the new CPT evaluation codes should not feel unfamiliar. Rather, they reaffirm precise documentation as a critical component of providing quality patient services.

    Definitions of the new evaluation codes point out that the level of evaluation complexity reported (low/moderate/high) is dependent on the PT's clinical decision making throughout the evaluation and course of care. The elements of the evaluation include:

    • History taking
    • Examination
    • Determining the patient's clinical presentation

    Table 1 illustrates the basic components that must be documented in order to report each level of evaluation complexity.

    Description of Elements

    For the purpose of reporting the physical therapy evaluation, body regions and body systems are defined as follows:

    Body regions: head, neck, back, lower extremities, upper extremities, and trunk

    Body systems: musculoskeletal, neuromuscular, cardiovascular and pulmonary, and integumentary

    A review of body systems includes the following:

    • For the musculoskeletal system: assessment of gross symmetry, gross range of motion, gross strength, height, and weight
    • For the neuromuscular system: general assessment of gross coordinated movement (eg, balance, gait, locomotion, transfers, and transitions) and motor function (motor control and motor learning)
    • For the cardiovascular and pulmonary system: assessment of heart rate, respiratory rate, blood pressure, and edema
    • For the integumentary system: assessment of pliability (texture), presence of scar formation, skin color, and skin integrity

    Review of any of the body systems also includes assessment of the patient's or client's ability to make his or her needs known, his or her level of consciousness and orientation (person, place, and time), his or her expected emotional/behavioral responses, and his or her learning preferences (eg, learning barriers and education needs).

    Body structures: the structural or anatomical parts of the body, such as organs, limbs, and their components, classified according to body systems

    Personal factors: include sex, age, coping styles, social background, education, profession, past and current experience, overall behavior pattern, character, and other elements that influence how disability is experienced by the individual

    Personal factors that exist but do not impact the physical therapy plan of care are not to be considered when selecting a level of service.

    APTA created the information in Table 2 to help guide you through the process of documenting your use of the new evaluation codes.

    Keep in mind that in order to support your code selection, you must clearly document each required component for that code. In other words, if even 1 component cannot be supported, you must report a lower level of complexity. There is no mandated format for the required documentation, but you should make the components readily apparent to all third parties that will be reading and reviewing your report of the patient's evaluation.

    Quality, Not Quantity

    Best-practice documentation doesn't necessarily require a lot of extra time and effort. But it does require answering the right questions and clearly demonstrating medical necessity.

    What does all of this mean to the payer? Even though the evaluation and reevaluation code descriptors are new, the following elements that were required with the old codes still must be clearly stated:

    Initial evaluation

    • What's wrong with the patient?
    • What's planned for the patient?
    • What skilled care will be necessary to achieve the goals outlined in the evaluation?


    • What measurable, objective progress was achieved since the initial evaluation was completed?
    • What was the outcome of the delivered service?
    • What was the patient status and prognosis at the time of reevaluation?

    Compliance Matters - Table 1

    Compliance Matters - Table 2

    Evans, Wanda 110x75

    Wanda K. Evans, PT, MHS, is senior payment specialist in the Department of Payment and Practice Management at APTA.  


    1. Evans WK. The keys to effective documentation. PT in Motion. 2016;8(7):8-12.


    Quick Guide to the 3 Levels of Physical Therapy Evaluation

    Use this downloadable PDF to become familiar with the new CPT evaluation codes.


    New Evaluation Codes for 2017: Self-Paced Course

    APTA's comprehensive online course is free to all and serves as an introduction to the new CPT codes. It offers patient scenarios for practice in selecting complexity levels.

    http://learningcenter.apta.org/; search for course LMS-749

    Payment Reform Discussion Forum

    The APTA Hub hosts a forum on the new evaluation codes within which all members can post questions and share insights. It's found within the Payment Reform community.


    Online Course From MedBridge

    APTA has partnered with MedBridge to deliver a 30-minute online course that explores the elements of an evaluation and the conditions that must be met for each level of complexity.


    New Evaluation Codes Recorded Webinar and Q&A

    This free recording of APTA's live webinar and follow-up Q&A session outlines the new codes. View or download it—and the accompanying handouts—from the APTA Learning Center.

    http://learningcenter.apta.org/; search for course LMS-810

    Compliance Matters: New CPT Evaluation Codes

    These PT in Motion magazine Compliance Matters columns offer insight into the new codes:

    • New CPT Evaluation Codes Are Here (February 2017)
    • New CPT Evaluation Codes (September 2016)



    Defensible Documentation

    APTA's tips for accurate and thorough documentation of your services can help you avoid denials.

    2017 Coding and Payment Guide for the Physical Therapist

    APTA members get a discount on this essential guide to coding and payment, cobranded with OPTUM.

    Documentation Training for new PT and OT Evaluation Codes Webinar From the National Association of Rehabilitation Providers and Agencies

    This online webinar includes case examples for acute care and skilled nursing facilities.


    CPT Professional Spiral 2017

    The American Medical Association's annual CPT manual contains the new evaluation codes and their official descriptors.


    New Patient Checklist: Verifying Insurance Benefits and Covered Services

    Most practices have a process to verify whether the patient is covered by insurance for the services provided, but there may be gaps in that process. This APTA resource lists questions you should incorporate into your telephone intake form to ensure that all bases are covered. It also offers tips for optimal tracking of communications with payers.

    www.apta.org/Payment/Billing/Patient Checklist/  

    APTA Center for Integrity in Practice Documentation Page

    The page includes links to numerous resources—some compiled by APTA, others by the federal government.


    Top 10 Payer Issues With Documentation

    From APTA's Center for Integrity in Practice, these are the most common reasons payers deny claims:

    1. Poor legibility
    2. Incomplete
    3. Date of service not documented
    4. Too many abbreviations, unfamiliar abbreviations
    5. Documentation does not support billing (coding)
    6. Documentation does not demonstrate skilled care
    7. Documentation does not support medical necessity
    8. Documentation does not demonstrate progress or maintenance of function, if that is the stated goal
    9. Daily notes are repetitious, showing no change in patient status
    10. No clarification of time, frequency, duration of interventions

    Source: http://integrity.apta.org/ReducingRisk/UnderstandingRisk/RiskAreas/Documentation/


    These are UNTIMED codes and are payed as such so why are you adding "suggested times"? These documented times have set us back in the progress we have been making with administrations on the value of PT and how productivity is calculated. Now that AMA has documented times next to the eval codes our conversations have shut down!! It may very well take longer than 20 min to see a low complexity patient if you are doing a quality eval!!
    Posted by Shannon Fox on 3/1/2017 9:12:18 AM
    Shannon, I agree. As soon as the times were suggested, at my facility complexity is now solely based on time and nothing else.
    Posted by Kira on 5/17/2017 10:35:37 PM
    Our hospitals are having issues with AARP Medicare Advantage plans. They will not recognize or remit on any of the 3 new PT codes. They are denying them as not payable. Do you have any suggestions on how to get one of the largest Medicare Advantage Plans to recognize the new codes. The volume of denials is maddening.
    Posted by Wendy Sumner on 5/26/2017 2:35:36 PM
    When billing Medicare for the new re-evaluation code 97164 my claims are being rejected when the 97110 or 97140 codes are also billed?? Do I need to use some type of modifier?? Thank you
    Posted by Paul Lysher on 6/14/2017 6:32:16 AM
    The reevaluation code 97164 is allowed to be reported with 97110 or 97140, per the NCCI edits table. (See https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html and https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEd/). Assuming the services were performed separately and independently of each other, it is recommended that when reporting these codes together to use modifier 59. The documentation must demonstrate that the services performed were distinct from one another and it must be ensured that a more descriptive modifier is not available. For additional information about modifier 59, see: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf.
    Posted by PT in Motion Editorial Staff -> CORc@H on 6/16/2017 1:55:45 PM
    In the acute care setting, if upon evaluation, I decide to discharge either due to independence or previous level of dependence with functional mobility, can I only classify the evaluation as low complexity since there is no further plan of care?
    Posted by Ericka Vargas on 9/17/2018 1:00:51 PM
    In 2016, in preparation for the 2017 new PT evaluation codes, there was a question if whether or not treatment codes could be billed on the same day as a new PT evaluation under Medicare B in the outpatient setting. Can you provide an update? Are suppliers being denied same day treatment claims?
    Posted by Patricia Spare -> @MV`=O on 12/22/2018 10:04:44 AM

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