Date: April 3, 2017
To: Enrolled Occupational Therapists; Physical Therapists; Physicians; Hospitals; Local Health Departments; Encounter Rate Clinics; Federally Qualified Health Centers; Rural Health Clinics ; and Community Health Agencies
Re: Current Procedural Terminology (CPT) Codes and Reimbursement Rates for Physical and Occupational Therapy Evaluations Effective January 1, 2017
The purpose of this notice
is to notify providers of changes to physical therapy (PT) and occupational
therapy (OT) evaluation CPT codes effective with dates of service on or after
January 1, 2017.
The following physical and
occupational therapy evaluation codes have been deleted and replaced with more
specific codes effective with dates of service on or after January 1, 2017:
·
97001 – Physical Therapy
Evaluation
·
97002 – Physical Therapy
Re-Evaluation
·
97003 – Occupational
Therapy Evaluation
·
97004 – Occupational
Therapy Re-Evaluation
The therapy fee schedule
will be updated with the following new codes, short descriptors, rates, and
maximum quantity amounts effective with dates of service on or after January 1,
2017. Hospitals that bill physical therapy as fee-for-service will continue
to be reimbursed at the same rate as CPT 97001, regardless of which new code is
billed.
CPT Code
|
Short Descriptor
|
Unit Price Child Age 0-20
|
Max Qty Child Age 0-20
|
State Max Child Age 0-20
|
Unit Price Adult Age 21+
|
Max Qty Adult Age 21+
|
State Max Adult Age 21+
|
97161
|
PT Eval Low Complexity
|
$12.99
|
8
|
$103.92
|
$9.00
|
4
|
$36.00
|
97162
|
PT Eval Moderate Complexity
|
$12.99
|
8
|
$103.92
|
$9.00
|
4
|
$36.00
|
97163
|
PT Eval High Complexity
|
$12.99
|
8
|
$103.92
|
$9.00
|
4
|
$36.00
|
97165
|
OT Eval Low Complexity
|
$12.99
|
8
|
$103.92
|
$9.00
|
4
|
$36.00
|
97166
|
OT Eval Moderate Complexity
|
$12.99
|
8
|
$103.92
|
$9.00
|
4
|
$36.00
|
97167
|
OT Eval High Complexity
|
$12.99
|
8
|
$103.92
|
$9.00
|
4
|
$36.00
|
Rates and maximum
quantities for the new codes are based on the same therapy rate structure that
was in place for the recently deleted codes. Maximum quantities billable
continue to represent 15-minute increments and remain at two hours for
children’s evaluations, and one hour for adult evaluations.
Due to changes in the PT
and OT evaluation code definitions, and specifically the component requirements
found in the long descriptors, providers must bill the code appropriate for the
complexity of the evaluation with a unit quantity equal to the number of
15-minute increments that represents time spent. Note that key components and
time spent should be documented in the participant’s medical record and must be
produced as necessary for audit purposes.
Re-evaluations
The physical therapy
re-evaluation CPT code 97002 has been replaced with 97164 effective January 1,
2017. The occupational therapy re-evaluation CPT code 97004 has been replaced
with 97168. Previously, CPT codes 97002 and 97004 were listed on the Therapy Fee Schedule Crosswalk
and linked to 97110 as the billable code for both PT and OT. The new
re-evaluation CPT codes 97164 and 97168 will also be cross walked to 97110,
with the applicable modifier, as the billable code. Maximum quantities billable
remain at one hour for both child and adult re-evaluations.
Claims Processing
A hold edit was implemented
on January 13, 2017 to temporarily suspend any claims received with one of the
new PT or OT evaluation CPT codes. Those claims will be released back into
processing for final adjudication once programmatic changes are implemented.
Final adjudication will be reported on a future Remittance Advice. Once the
held claims are adjudicated, providers will need to submit replacement claims
for any services that were billed with an incorrect procedure code and/or
quantity prior to notification of the above guidance.
Questions may be directed
to a therapy billing consultant in the Bureau of Professional and Ancillary
Services at 1-877-782-5565.
Felicia
F. Norwood
Director
Director
