CPT Codes and Reimbursement Rates

Date:   April 3, 2017

To:       Enrolled Occupational Therapists; Physical Therapists; Physicians; Hospitals; Local Health Departments; Encounter Rate Clinics; Federally Qualified Health Centers;  Rural Health Clinics ; and Community Health Agencies

Re:      Current Procedural Terminology (CPT) Codes and Reimbursement Rates for Physical and Occupational Therapy Evaluations Effective January 1, 2017

The purpose of this notice is to notify providers of changes to physical therapy (PT) and occupational therapy (OT) evaluation CPT codes effective with dates of service on or after January 1, 2017.

The following physical and occupational therapy evaluation codes have been deleted and replaced with more specific codes effective with dates of service on or after January 1, 2017:

·       97001 – Physical Therapy Evaluation

·       97002 – Physical Therapy Re-Evaluation

·       97003 – Occupational Therapy Evaluation

·       97004 – Occupational Therapy Re-Evaluation

The therapy fee schedule will be updated with the following new codes, short descriptors, rates, and maximum quantity amounts effective with dates of service on or after January 1, 2017.  Hospitals that bill physical therapy as fee-for-service will continue to be reimbursed at the same rate as CPT 97001, regardless of which new code is billed.

Rates and maximum quantities for the new codes are based on the same therapy rate structure that was in place for the recently deleted codes. Maximum quantities billable continue to represent 15-minute increments and remain at two hours for children’s evaluations, and one hour for adult evaluations.

Due to changes in the PT and OT evaluation code definitions, and specifically the component requirements found in the long descriptors, providers must bill the code appropriate for the complexity of the evaluation with a unit quantity equal to the number of 15-minute increments that represents time spent. Note that key components and time spent should be documented in the participant’s medical record and must be produced as necessary for audit purposes.

Re-evaluations

The physical therapy re-evaluation CPT code 97002 has been replaced with 97164 effective January 1, 2017. The occupational therapy re-evaluation CPT code 97004 has been replaced with 97168. Previously, CPT codes 97002 and 97004 were listed on the Therapy Fee Schedule Crosswalk and linked to 97110 as the billable code for both PT and OT. The new re-evaluation CPT codes 97164 and 97168 will also be crosswalked to 97110, with the applicable modifier, as the billable code. Maximum quantities billable remain at one hour for both child and adult

re-evaluations.

Claims Processing

A hold edit was implemented on January 13, 2017 to temporarily suspend any claims received with one of the new PT or OT evaluation CPT codes. Those claims will be released back into processing for final adjudication once programmatic changes are implemented. Final adjudication will be reported on a future Remittance Advice. Once the held claims are adjudicated, providers will need to submit replacement claims for any services that were billed with an incorrect procedure code and/or quantity prior to notification of the above guidance.

Questions may be directed to a therapy billing consultant in the Bureau of Professional and Ancillary Services at 1-877-782-5565.

Felicia F. Norwood

Director

CPT Codes and Reimbursement Rates

Date:   April 3, 2017

To:       Enrolled Occupational Therapists; Physical Therapists; Physicians; Hospitals; Local Health Departments; Encounter Rate Clinics; Federally Qualified Health Centers;  Rural Health Clinics ; and Community Health Agencies

Re:      Current Procedural Terminology (CPT) Codes and Reimbursement Rates for Physical and Occupational Therapy Evaluations Effective January 1, 2017

The purpose of this notice is to notify providers of changes to physical therapy (PT) and occupational therapy (OT) evaluation CPT codes effective with dates of service on or after January 1, 2017.

The following physical and occupational therapy evaluation codes have been deleted and replaced with more specific codes effective with dates of service on or after January 1, 2017:

·       97001 – Physical Therapy Evaluation

·       97002 – Physical Therapy Re-Evaluation

·       97003 – Occupational Therapy Evaluation

·       97004 – Occupational Therapy Re-Evaluation

The therapy fee schedule will be updated with the following new codes, short descriptors, rates, and maximum quantity amounts effective with dates of service on or after January 1, 2017.  Hospitals that bill physical therapy as fee-for-service will continue to be reimbursed at the same rate as CPT 97001, regardless of which new code is billed.

Rates and maximum quantities for the new codes are based on the same therapy rate structure that was in place for the recently deleted codes. Maximum quantities billable continue to represent 15-minute increments and remain at two hours for children’s evaluations, and one hour for adult evaluations.

Due to changes in the PT and OT evaluation code definitions, and specifically the component requirements found in the long descriptors, providers must bill the code appropriate for the complexity of the evaluation with a unit quantity equal to the number of 15-minute increments that represents time spent. Note that key components and time spent should be documented in the participant’s medical record and must be produced as necessary for audit purposes.

Re-evaluations

The physical therapy re-evaluation CPT code 97002 has been replaced with 97164 effective January 1, 2017. The occupational therapy re-evaluation CPT code 97004 has been replaced with 97168. Previously, CPT codes 97002 and 97004 were listed on the Therapy Fee Schedule Crosswalk and linked to 97110 as the billable code for both PT and OT. The new re-evaluation CPT codes 97164 and 97168 will also be crosswalked to 97110, with the applicable modifier, as the billable code. Maximum quantities billable remain at one hour for both child and adult

re-evaluations.

Claims Processing

A hold edit was implemented on January 13, 2017 to temporarily suspend any claims received with one of the new PT or OT evaluation CPT codes. Those claims will be released back into processing for final adjudication once programmatic changes are implemented. Final adjudication will be reported on a future Remittance Advice. Once the held claims are adjudicated, providers will need to submit replacement claims for any services that were billed with an incorrect procedure code and/or quantity prior to notification of the above guidance.

Questions may be directed to a therapy billing consultant in the Bureau of Professional and Ancillary Services at 1-877-782-5565.

Felicia F. Norwood

Director