Complexity CPT codes for OT and PT

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 Re-Evaluation – CPT 97164 (was previously 97002)

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

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-to face 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-to face 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