Summary

Physical Therapy Complexity
Minutes History Examination Clinical Presentation Decision Making
Low 20 no personal factors / comorbidities 1-2 elements stable and/or uncomplicated Low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome
Moderate 30 1-2 personal factors / comorbidities 3+ elements changing characteristics Moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome
High 45 3+ personal factors / comorbidities 4+ elements unstable and unpredictable characteristics High complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome
Reeval 20

 

Occupational Therapy Complexity
Minutes History Examination Decision Making
Low 30 Brief history including review of records 1-3 deficits analysis of occupational profile, problem-focused assessments, and limited number of treatment options. Patient presents with no comorbidities. No modification of tasks or assistance with assessments is necessary.
Moderate 45 Expanded review of  records and history 3-5 deficits analysis of occupational profile, detailed assessments, and several treatment options.
Patient may present with comorbidities. Minimal to moderate modification of tasks or assistance with assessments is necessary.
High 60 Extensive review of  records and history 5+ deficits analysis of patient profile, comprehensive assessments, and multiple treatment options.
Patient presents with comorbidities. Significant modification of tasks or assistance with assessments.
Reeval 30

CPT 97001  will be replaced with the following evaluation codes as of 1/1/2017

  • PT Evaluation – Low Complexity – CPT 97161
  • PT Evaluation – Moderate Complexity – CPT 97162
  • PT Evaluation – High Complexity – CPT 97163

PT Re-Evaluation – CPT 97164  (was previously 97002)

 

CPT 97003 – will be replaced with the following evaluation codes as of 1/1/2017:

  • OT Evaluation – Low Complexity – CPT 97165
  • OT Evaluation – Moderate Complexity – CPT 97166
  • OT Evaluation – High Complexity – CPT 97167

OT Re-Evaluation – CPT 97168 (was previously 97004)

 

Four key components that therapists will use to select appropriate evaluation CPT code:

  • Patient history and comorbidities
  • Examination and the use of standardized tests and measures
  • Clinical presentation
  • Clinical decision making

 

Physical Therapy Complexity:

  • Low Complexity – Typically, 20 minutes are spent face-to-face with the patient and/or family
  • Moderate Complexity – Typically, 30 minutes are spent face-to-face with the patient and/or family
  • High Complexity – Typically, 45 minutes are spent face-toface with the patient and/or family
  • Reevaluation – Typically, 20 minutes are spent face-to-face with the patient and/or family

Occupational Therapy Complexity:

  • Low Complexity – Typically, 30 minutes are spent face-to-face with the patient and/or family
  • Moderate Complexity – Typically, 45 minutes are spent face-to-face with the patient and/or family
  • High Complexity – Typically, 60 minutes are spent face-toface with the patient and/or family
  • Reevaluation – Typically, 30 minutes are spent face-to-face with the patient and/or family

 

 

PT Evaluation – Low Complexity

  • History – A history with no personal factors and/or comorbidities that impact the plan of care
  • Examination – An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions
  • Clinical Presentation – A clinical presentation with stable and/or uncomplicated characteristics
  • Decision Making – Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome

OT Evaluation – Low Complexity

  • History – An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem
  • Examination – An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions
  • Decision Making – Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component

PT Evaluation – Moderate Complexity

  • History – A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care
  • Examination – An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions
  • Clinical Presentation – An evolving clinical presentation with changing characteristics
  • Decision Making – Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome

OT Evaluation – Moderate Complexity

  • History – An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance
  • Examination – An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions
  • Decision Making – Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component

PT Evaluation – High Complexity

  • History – A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care
  • Examination – An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions
  • Clinical Presentation – A clinical presentation with unstable and unpredictable characteristics
  • Decision Making – Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome

OT Evaluation – High Complexity

  • History – An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance
  • Examination – An assessment(s) that identify 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions
  • Decision Making – A clinical decision-making is of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component

Factors That Impact Level of Evaluation

  • Patient’s age
  • Time since onset of injury/illness/exacerbation
  • Mechanism of injury/illness/exacerbation
  • 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 patient

Evaluation Codes Definitions

  • Body Regions – Head, neck, back, lower extremities, upper extremities, and Trunk
  • Body Systems – Circulatory, Skeletal, Muscular, Nervous, Respiratory, Immune, Excretory, Integumentary, Lymphatic, Cardiovascular, Reproductive and Digestive
  • Body Structures – Structural or anatomical parts of body, such as organs, limbs and their components classified according to body systems
  • Body Functions – Physiological functions of body systems