January 1 will put new evaluation codes for physical and occupational therapy into effect and we all better be paying close attention.

Coding will no longer be as simplistic, relatively speaking. The code sets will have three tiered levels, based on level of patent complexity, clinical presentation and results of standardized testing. 

This is an area that therapists are struggling to understand and to that, I say keep up the good fight. This is very important material and it’s not going away.

The efforts to replace the current evaluation code sets follows a multi-year collaboration between the American Occupational Therapy Association, the American Physical Therapy Association, and the American Medical Association’s CPT® Editorial Panel and Relative Value Scale Update Committee (RUC).

What you need to know

1.  Each therapy discipline will have three new codes with descriptors based on levels of complexity: low, moderate and high.

2.  The prior therapy evaluation codes 97001, Physical Therapy Evaluation; 97002, Physical Therapy Re-evaluation; 97003, Occupational Therapy Evaluation; and 97004, Occupational Therapy Re-evaluation will be deleted from the CPT® code set and should not be used for any evaluations from Jan. 1, 2017 onward.

Physical therapy evaluation codes entail key components including: body regions, body systems, body structures and personal factors.

3.  Occupational therapy evaluations codes involve key components including: physical, cognitive and psychosocial skills.

4.  CMS did reconsider the proposed rule value of the new re-evaluation codes in order to account for changes in practice since 1997, therefore adopting the original proposal from the RUC of .75.

5.  In lieu of delaying implementation of evaluation codes themselves, the Centers for Medicare & Medicaid Services state it will delay (at least over this first year) making changes to the Medicare Benefits Policy Manual regarding new documentation requirements for the new evaluation levels.

New Codes Defined

Physical Therapy Evaluations


The level of the physical therapy evaluation performed is dependent on clinical decision-making and on the nature of the patient’s condition (severity).

Body regions and body systems are defined as follows:

Body regions: head, neck, back, lower extremities, upper extremities and trunk

Body systems: musculoskeletal, neuromuscular, cardiovascular pulmonary and integumentary.

Body structures: the structural or anatomical parts of the body, such as organs, limbs and their components, classified according to body systems.

Personal factors: Factors that include sex, age, coping styles, social background, education, profession, past and current experience, overall behavior pattern, character, and other factors that influence how disability is experienced by the individual. Personal factors that exist but do not impact the physical therapy plan of care are not to be considered, when selecting a level of service.

(Source: CPT 2017 Professional Edition)

Occupational Therapy Evaluations


The level of the occupational therapy evaluation performed is determined by patient condition, complexity of clinical decision-making, and the scope and nature of the patient’s performance deficits relating to physical, cognitive or psychosocial skills to be assessed.

The patient’s plan of treatment should reflect assessment of each of the identified performance deficits.

Performance deficits: Refers to the inability to complete activities due to the lack of skills in one or more of the categories below (i.e. relating to physical, cognitive or psychosocial skills):

•  Physical skills: Refers to impairments of body structure or body function (e.g. balance, mobility, strength, endurance, fine or gross motor coordination, sensation and dexterity).

•  Cognitive skills: Refers to the ability to attend, perceive, think, understand, problem solve, mentally sequence, learn and remember, resulting in the ability to organize occupational performance in a timely and safe manner.

•  Psychosocial skills: Refers to interpersonal interactions, habits, routines and behaviors, active use of coping strategies, and/or environmental adaptations to develop skills necessary to successfully and appropriately participate in everyday tasks and social situations.

(Source: CPT 2017 Professional Edition)

Still have questions?

The American Physical and Occupational Therapy Associations have developed a number of tools to assist therapists with navigating the new coding process.

American Occupational Therapy Association (AOTA), Descriptors of New CPT Occupational Therapy Evaluation Codes, derived from: http://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Coding/evaluation-cpt-codes-descriptors.aspx

American Physical Therapy Association (APTA), New Physical Therapy Evaluation and Reevaluation CPT Codes, derived from: http://www.apta.org/PaymentReform/NewEvalReevalCPTCodes/

Renee Kinder, MS, CCC-SLP, RAC-CT, currently serves as Director of Clinical Education for Encore Rehabilitation and acts as editor of Perspectives on Gerontology, a publication of the American Speech Language Hearing Association.