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How to Prevent CPT Coding Errors in 2017

November 16, 2016
Healthcare Consulting By LW Consulting Inc.

CPT_Coding_Nurse.jpgCY 2017 marks a set of new code changes for PT and OT evaluations. That's right…new year, new codes! There are three PT evaluation codes, three OT evaluation codes, and one new reevaluation code for each specialty that  will change the way PTs and OTs bill for evaluations.

These new codes reflect a 3-tier coding system based on the complexity level of the patient's presentation and clinician's clinical decision making. They are rated as Low complexity, Moderate complexity, and High complexity. All physical and occupational therapists should get to know and understand these new codes prior to the effective date of January 1, 2017 to avoid denials and rejected claims.

What You Need to Know to Prevent CPT Coding Errors

Beginning January 1, all Medicare Part B PT and OT claims must utilize these new codes, or the claims will be rejected. While Medicare will not be paying differently for the different levels of evaluation, they are using the minutes billed for each of the evaluation codes to determine payment rates in the future. It is critical that the claims submitted now accurately reflect the varying time it takes to gather and analyze the different levels of evaluation data.

Other payors covered under HIPAA requirements, such as Medicare Managed Care, Tricare, and most private insurance payors will also require these new codes. Those payors may independently set different payment rates for different code levels; and if they do so, you can expect that there may be a future audit for the documentation that supports the various codes.

Entities that are not covered under HIPAA requirements, such as workmans' comp or auto liability insurers may continue to use the old codes. So your billing software may need to handle both code sets if you bill these providers.

Ensure that your therapists are taking credit for the level of complexity and professional decision-making that their patients’ needs require. Below is a breakdown of the new codes going into effect January 1, 2017:

97X61

Physical therapy evaluation: low complexity requiring these components:

  • A history with no personal factors and/or comorbidities that impact the plan of care;
  • 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 decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
  • A clinical presentation with stable and/or uncomplicated characteristics; and

Typically, 20 minutes are spent face-to-face with the patient and/or family.

97X62 Physical therapy evaluation: moderate complexity requiring these components:
  • A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;
  • 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;
  • An evolving clinical presentation with changing characteristics; and
  • Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 30 minutes are spent face-to-face with the patient and/or family.
97X63 Physical therapy evaluation: high complexity requiring these components:
  • A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care;
  • 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;
  • A clinical presentation with unstable and unpredictable characteristics; and
  • Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 45 minutes are spent face-to-face with the patient and/or family.
97X64  Reevaluation of physical therapy established plan of care requiring these components:
  • An examination including a review of history and use of standardized tests and measures is required; and
  • Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome

Typically, 20 minutes are spent face-to-face with the patient and/or family.

 

Get Ready to Crack the CPT Code with training from LW Consulting.