Ringing in 2017 with New Physical Therapy Evaluation and Re-Evaluation Codes
By Katie Pring, MPT
Starting January 1, 2017, physical therapists will have three new evaluation codes and one new re-evaluation code. The new evaluation codes will replace the 97001, PT initial evaluation, and 97002, PT reevaluation codes.
In addition, the three new physical therapy evaluation codes are further divided into three levels of complexity: low, moderate, and high. Listed are the new evaluation codes for 2017:
- 97161: Physical Therapy Evaluation–Low Complexity Evaluation
- 97162: Physical Therapy Evaluation–Moderate Complexity Evaluation
- 97163: Physical Therapy Evaluation–High Complexity Evaluation
- 97164: Re-evaluation
The new initial evaluation codes are based on four components: patient history, examination, clinical presentation, and clinical decision making. Together, these four components of the evaluation determine which evaluation code to use.
The following charts can be used to help guide a therapist in determining the complexity of the evaluation. Please note when choosing the complexity of the evaluation, all components must be met and documented. If one of the four components is not met and documented, the therapist must default to a lower complexity evaluation code.
97161: PT Evaluation Low Complexity Evaluation
| Patient History | Examination | Clinical Presentation | Clinical Decision Making |
| No documented comorbidities or personal factors that impact the plan of care. | Documented 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions | Stable and/or uncomplicated characteristics | Low complexity |
97162: PT Evaluation Moderate Complexity
| Patient History | Examination | Clinical Presentation | Clinical Decision Making |
| Documented 1-2 comorbidities and/or personal factors that impact the plan of care | Documented 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions | Evolving clinical presentation with changing characteristics | Moderate complexity |
97163: PT Evaluation High Complexity
| Patient History | Examination | Clinical Presentation | Clinical Decision-making |
| Documented 3-4 comorbidities and/or personal factors that impact the plan of care | Documented 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions | Unstable and unpredictable characteristics | High complexity |
The new evaluation codes will be accepted by all insurances with the exception of workman compensation and/or auto insurance providers. It is recommended to follow-up with workman comp and auto insurance providers to see if they will be accepting the new evaluation codes.
At this time, all three initial evaluation codes will be reimbursed at the same fee scale. Reimbursement will not increase based on the complexity of the evaluation code. In 2017, CMS will study the utilization of the evaluation codes to determine if there different fees should apply for different evaluation codes.
In upcoming months, APTA will continue to educate physical therapists on the usage of the new evaluation codes. In addition, APTA is planning to have patient case scenarios that will allow therapists to review the case and practice determining which evaluation code to use. The Section on Women’s Health will have several patient examples on our reimbursement webpage in months to come.
Author: SOWH Reimbursement Committee member Katie Pring, MPT, works in the outpatient orthopedic practice of Mendelson Kornblum Orthopedics in Warren, Mich. The women’s health program she developed there includes treatment of lymphedema, pregnancy and postpartum care, and pelvic floor therapy.
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