• News New Blog Banner

  • New CPT Codes Result in Payment Increases From Medicare

    A bit of good news for physical therapists (PTS): thanks to a change in the formula the Centers for Medicare and Medicaid Services (CMS) uses when calculating reimbursement, the new Current Procedural Terminology (CPT) code set for physical therapy evaluation and reevaluation is generating higher payments.

    Just how much of an increase PTs are seeing depends on geographic region and whether the payment is for an evaluation or revaluation associated with a Medicare Part B beneficiary (APTA members will be able to identify if they will receive payment increases through an updated online Medicare payment calculator coming to the association's website soon). Some commercial payers may also be affected by the changed formula, depending on how contracts are written.

    The altered elements of the formulas are related to 2 areas: the "practice expense" relative value unit (RVU) and the "work" RVU. The practice expense RVU reflects the costs of maintaining a practice, while the work RVU is focused on the relative time and intensity associated with furnishing the service. The formula changes associated with the reevaluation code includes alterations to both RVUs, while the change to the evaluation code formula involves only the practice expense RVU. Overall the increases are consistent with changes advocated by APTA during CMS' development of the 2017 physician fee schedule—the rule that includes the new 3-tiered CPT code set.

    According to Carmen Elliott, APTA's vice president of payment and practice management, the increase is definitely a win for PTs—but not something that should cause them to take their eyes off the ball when it comes to payment reform in general, and CPT coding in particular.

    "This change is something that PTs definitely should feel good about," Elliott said. "But the fact is, we should expect even bigger changes in the future, and PTs need to remain engaged by learning as much as they can about how to use the new CPT codes properly, because what they do now will shape the future of payment in the long-term."

    APTA provides multiple resources to help PTs understand and properly use the new code set, including an upcoming Q-and-A webinar and an online course created in partnership with CEU provider MedBridge. APTA members can also join conversations about the CPT codes and other issues by participating in the association's online community focused on payment reform.

    Labels: None


    • Bravo!! Thank you for your hard work on this. What seemed impossible became possible.

      Posted by Karen Shuler on 1/7/2017 8:51 AM

    • The title of this is quite misleading, isn't it, as the reason the fees increase is not due to the new codes but due to CMS reassessing a component of the codes which occurs annually due to the potential for change to these components. Correct me if I am wrong, please. THanks.

      Posted by Flo Moses on 1/10/2017 1:25 PM

    • The reimbursement for the eval codes goes up, but the cap is relatively the same. This doesn't really add up to increased reimbursement. I could be wrong, but the math seems to point to the patients reaching the cap w/ fewer visits.

      Posted by Paul Christensen on 1/11/2017 5:38 PM

    • I don't think the association is lobbying hard enough to improve reimbursements. The cap is still the same. But now the way I see is that it gets even harder to get reimburse.

      Posted by Jay Patel -> AMU\DJ on 1/12/2017 11:22 AM

    • Not to mention the 30 minutes of additional paperwork to justify the couple extra dollars of payment...which equals a net loss...

      Posted by Ehren Trost on 1/12/2017 3:37 PM

    • I have to agree with Flo that the title is a bit misleading. We all know that the ultimate hope was that CMS would stratify payments based on which complexity code was chosen. While the article does explain what the source of the increase is, I think maybe it should have clarified that there is no change to the final rule that did not tier payments. Having said that, this is a win. Yes, the cap is arbitrary and needs repealing but it will happen. Ehren, 30 min is likely an exaggeration. You should be documenting most of the required elements already. It's just a matter of organizing your documentation to better reflect it. I'm not saying it's perfect but we modified our EMR templates and our staff has been reporting 5-10 min extra so far.

      Posted by Jeremy Ramage -> >GP]EO on 1/13/2017 9:08 AM

    • Article somewhat misleading. Slight increase in reimbursement from 97001 to the ne codes this year. But at this time all the new evaluation CPT codes will be reimbursed the same.. or has something changed?

      Posted by Kevin O'Sullivan on 1/18/2017 11:02 AM

    • thanks for posting this useful article...being a medical coder l like to read all updates about medicare and cpt code...!!

      Posted by Jitendra on 11/14/2017 10:02 AM

    Leave a comment
    Name *
    Email *