Preparing for the New Therapy Evaluation Codes

Nov 25

The time is now to start preparing for the new evaluation and re-evaluation codes that will go into effect on January 1st, 2017.  As mentioned in the previous blog post, the current PT and OT evaluation and re-evaluation codes have been removed from the AMA CPT manual and replaced with three new evaluation codes and one new re-evaluation code for each discipline.  All HIPAA-covered entities, which includes Medicare and commercial payers, will be required to switch to the new codes on January 1st.  This post will go into a little more detail on the new codes including a review of some of the terminology associated with determining the various complexity levels.


All six new evaluation codes and both new re-evaluation codes will be subject to Medicare’s multiple procedure payment reduction (MPPR) and will be subject to the annual therapy caps.  As they are considered “always therapy” CPT codes, they will also require a therapy modifier (GP or GO) for Medicare claims.

CMS has elected not to value the evaluation codes differently for 2017, which means all three evaluation codes PT will be paid the same as will the OT evaluation codes.  The finalized work RVU of 1.2 for all six eval codes is the same as the current evaluation codes (97001 and 97003).  Additionally, CMS will delay making any changes to their current instructions for documentation of evaluations and re-evaluations in the Medicare Benefits Policy Manual to allow clinicians time to become more familiar with the codes and the documentation required in the medical record to support the billing of the applicable evaluation CPT code.

As the therapists transition to the new codes, they will need to understand that while coding to a higher complexity without the documentation to support that level will eventually lead to denials, it is equally important not to down-code to a lower complexity code simply because they may worry that their documentation doesn’t support a higher level of complexity.


Let’s now take a look at the four elements that must be addressed when determining the level of complexity for the physical therapy evaluation codes along with some of the associated terminology for each component.


The history component of the evaluation includes co-morbidities and “personal factors” that may impact the patient’s function and/or the patient’s ability to progress with the plan of care.  “Personal factors” can include the patient’s age, gender, genetic factors, cultural preferences, personality and attitudes, lifestyle, social background, education, profession, and physical factors such as handedness or BMI.  Environmental factors should also be considered and can include physical factors, social factors, and services.  Examples of environmental factors that could play a role in the plan of care might include the number of stairs the patient has to navigate to enter or once inside the home, if the patient has pets in the home, the patient’s transportation needs, or the patient’s reliance on adaptive equipment to perform tasks.   Additionally, it is important to document the patient’s previous functional level, the context of current functional abilities, and any treatment approaches the patient may have undergone in the past.

Co-morbidities that may have an impact on the patient’s ability to progress and achieve goals should also be documented as these can make for a more challenging clinical management of the patient’s condition.  Co-morbidities could create the potential for a poorer prognosis, poorer clinical outcomes, and increased duration of care.  Examples of co-morbidities may include obesity, diabetes, hearing loss, vision loss, cognitive deficits, osteopenia, and osteoarthritis. It is important to keep in mind that personal factors or co-morbidities that exist but that do not have an impact on the therapy plan of care should not be considered when selecting the level of service, that is to say the complexity of the evaluation.  The documentation must clearly indicate how the personal factors and/or co-morbidities affect the patient’s condition and plan of care.


The examination component of the evaluation includes the exam of body systems using standardized tests and measures addressing body structures and functions, activity limitations, and/or participation restrictions.  While these terms may not be all that familiar to therapists at first glance, they refer to aspects of the evaluation that are already being addressed.  The following paragraphs will go into each of these in a little more detail  Also, the International Classification of Functioning, Disability and Health (ICF) website ( is an excellent resource in helping to provide a clearer picture of these terms.

Body structures are defined as anatomical parts of the body such as organs, limbs, and their components.  The ICF breaks down the body structures into eight categories including structures of the nervous system, skin and related structures, and structures related to movement, just to name a few.  These are further broken down into more detail and include components of these various body structures.  For example, the “structures related to movement” category is broken down into various regions of the body with bones, joints, muscles, ligaments, etc. of these regions listed as separate body structures. The documentation would need to identify the various structures that were examined.

Body functions are defined as physiological functions of body systems and can include mental functions, sensory functions and pain, voice and speech functions, skin, and neuromusculoskeletal and movement-related functions among others.  These are further broken down into subcategories which relate to more specific functions.  For example, the neuromusculoskeletal and movement-related functions category includes functions pertaining to mobility of joints, stability of joints, mobility of bone, muscle power, muscle tone, and muscle endurance.

Activity limitations are difficulties an individual may have in executing activities which include tasks or actions as well as ADLs such as self-care, meal prep, and personal hygiene.  Several of the ICF subcategories pertaining to activities may be familiar to clinicians as these are referenced in functional limitation reporting, such as self-care (e.g. eating, dressing, washing, etc.) changing and maintaining body position; walking and moving around; and carrying, moving, and handling objects.

Participation restrictions are problems an individual may experience when involved in life situations and how they are able to function as a member of society.  Community life, recreation and leisure, religion and spirituality, and social and civic life are areas where a patient may be restricted from participation.  These instrumental ADLS (or IADLS) can facilitate greater levels of independence and an overall better quality of life for the patient.


The clinical presentation is an amalgamation of your clinical findings, as well as the patient’s pre-morbid and current level of function.  The documentation should indicate whether the patient’s condition is stable and uncomplicated (low complexity), evolving with changing characteristics (moderate), or evolving with unstable and unpredictable characteristics (high).  For example, a patient with back pain that has been steadily increasing over the last two weeks and occasionally prevents the patient from standing for more than 15 minutes at a time at various times during the day may be considered as presenting with a condition that is evolving with changing characteristics (moderate complexity).  A patient with poorly-controlled diabetes may be considered a high complexity because of unstable or unpredictable blood sugar.


This last component of the evaluation is the clinical decision-making in which the therapist must use his or her clinical judgment incorporating all the information collected in the history and examination.  This will also include a standardized patient assessment instrument and/or measurable assessment of the functional outcome.

Looking at the big picture, factors that may have an impact on the level of evaluation may include:

  • Patient’s age
  • Time since onset of injury/illness/exacerbation
  • Mechanism of injury
  • Past medical and surgical history
  • Co-morbidities and their impact on improvement
  • Prior level of function
  • Current level of function
  • Status of current condition
  • Patient’s cognitive status and safety concerns
  • Patient’s level of motivation
  • Patient’s home situation (environment and family support)
  • Objective examination findings
  • Goals and goal agreement with the patient
  • Rehab potential (prognosis) and probable outcome
  • Expected progression of the patient

Lastly, therapists should keep in mind that each component of the evaluation must meet or exceed the corresponding complexity requirement in order to select that code.  For example, if the documentation supports a high complexity in all but one of the components and a moderate complexity in the other, the evaluation would be coded as moderate complexity.

Stay tuned for more info as we near the January 1st conversion date.  As always, feel free to ask any questions in the comment section.