CPT Evaluation Codes Changing January 1, 2017

On January 1, 2017, the PT initial evaluation and reevaluation codes (97001 and 97002) will disappear from the AMA’s CPT coding. Poof. Just like that. That’s right, the AMA will replace codes 97001 and 97002 with 97161, 97162, 97163 (for low, moderate and high complexity initial evaluations) and 97164 (reevaluations).

This will affect claims for all HIPAA entities (Medicare, Medicaid, HMSA, etc.) but for the time being may NOT affect motor vehicle and worker’s compensation payments until those payers decide to join in on the band wagon. HAPTA has confirmed with the Hawaii State Department of Labor and Industrial Relations and the Hawaii Insurance Division that they will continue to use the Worker’s Compensation Supplemental Medical Fee Schedule from January 2014. This means, the DLIR and Motor Vehicle Claims will continue to accept the 97001 and 97002 codes and its associated multiplier (which is 3.0 and 1.6 respectively).

Despite the wide acceptance of changing the codes from one evaluation code to three for varying complexity, CMS did NOT accept APTA’s recommendation of a tiered fee schedule to go along with the tiered CPT codes. They will stick with one fee for all levels of complexity. Since all initial evaluation (IE) codes will be paid at the same amount, you may wonder if you should use only one code for simplicity’s sake despite the patient’s complexity. APTA strongly discourages selecting the same initial evaluation code for all of your initial evals because we will need accurate data about the utilization of codes as we continue this conversation with CMS. Let’s not shoot ourselves in the foot. Therapists will need to meet the criteria of appropriate IE code selection with documentation. In other words, more than ever your clinical documentation will need to show medical necessity and a focus on function to support your selection of the most appropriate code for the patient at that point in time. APTA will offer training courses on how to select the correct initial evaluation code starting in November, so be on the look-out and sign up.

Patti Taira-Tokuuke
HAPTA Payer Relations Committee Co-Chair

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