Physical Medicine and Rehabilitation codes 97001-97006 have been deleted and the section expanded to define new documentation requirements for evaluations and re-evaluations. Prior to 1/1/2017, the only criterion was whether the evaluation was an initial evaluation or a re-evaluation. Now, the provider must document some type of history, examination, clinical decision making, and plan of care to determine the complexity of the level of service provided: Low, Moderate, or High.

Coders are now directed CPT codes 97161-97164 for physical therapy evaluations, CPT codes 97165-97168 for occupational therapy evaluations, and CPT codes 97169-97172 for athletic training evaluations. Below are the new codes and requirements for each level of service:

  • 97161, “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
    • A clinical presentation with stable and/or uncomplicated characteristics
    • Clinical decision making of low complexity using 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.”

  • 97162, “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 limitation, and/or participation restrictions
    • An evolving clinical presentation with changing characteristics
    • 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.”

  • 97163, “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
    • 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.”

  • 97164, “Re-evaluation 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
    • 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.”

  • 97165, “Occupational therapy evaluation, low complexity, requiring these components:
    • 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
    • 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
    • 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 assessments(s) is not necessary to enable completion of evaluation component

Typically, 30 minutes are spent face-to-face with the patient and/or family.”

  • 97166, “Occupational therapy evaluation, moderate complexity, requiring these components:
    • 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
    • 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
    • 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

Typically, 45 minutes are spent face-to-face with the patient and/or family.”

  • 97167, “Occupational therapy evaluation high complexity, requiring these components:
    • 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
    • An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitation and/or participation restrictions
    • Clinical decision making 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 present 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

Typically, 60 minutes are spent face-to-face with the patient and/or family.”

  • 97168, “Re-evaluation of occupational therapy established plan of care, requiring these components:
    • An assessment of changes in patient functional or medical status with revised plan of care
    • An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals
    • A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.

Typically, 30 minutes are spent face-to-face with the patient and/or family.”

  • 97169, “Athletic training evaluation, low complexity, requiring these components:
    • A history and physical activity profile with no comorbidities that affect physical activity
    • An examination of affected body area and other symptomatic or related systems addressing 1-2 elements from any of the following body structures, physical activity, and/or participation deficiencies
    • Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome

Typically, 15 minutes are spent face-to-face with the patient and/or family.”

  • 97170, “Athletic training evaluation, moderate complexity, requiring these components:
    • A medical history and physical activity profile with 1-2 comorbidities that affect physical activity
    • An examination of affected body area and other symptomatic or related systems addressing a total of 3 or more elements from any of the following: body structures, physical activity, and/or participation deficiencies
    • 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.”

  • 97171, “Athletic training evaluation, high complexity, requiring these components:
    • A medical history and physical activity profile, with 3 or more comorbidities that affect physical activity
    • A comprehensive examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures, physical activity, and/or participation deficiencies
    • Clinical presentation with unstable and unpredictable characteristics
    • 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.”

  • 97172, “Re-evaluation of athletic training established plan of care requiring these components:
    • An assessment of patient’s current functional status when there is a documented change
    • A revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome with an update in management options, goals, and interventions

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

Coders are cautioned that the meanings of the terms used in the physical therapy codes are different the E/M Guidelines. Specifically, “do not use the Definitions of Commonly Used Terms in the Evaluation and Management (E/M) for Physical Medicine and Rehabilitation services.”