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.