how to code a re-evaluation for physical therapy icd-10-cm

by Haley Eichmann 5 min read

What is a CPT code for PT evaluation?

CPT® code descriptors for PT and OT evaluative procedures include specific components required for reporting, as well as the corresponding typical face-to-face times for each service. These evaluation codes require assigning a low-, moderate-, or high-complexity level to the therapy evaluation.

How do you code a therapy diagnosis?

A therapy diagnosis may be an impairment, activity limitation, or disability such as dysphasia (R47.02) or difficulty walking (R26.2). Always code to the greatest level of specificity based on the documentation provided. Claims can be denied for using unspecified or incorrect diagnosis codes.

Do you need an evaluation code for post-op treatment?

The catch in this situation is that some commercial payers may consider the post-op treatment period a new episode of care, in which case you’d need to use an evaluation code. Example: You treat a patient for osteoarthritis.

What is the CPT code for manual therapy?

Code 97140 reports the provision of manual (soft tissue and joint) therapy techniques for treatment of symptoms and impairments that might include limited range of motion, muscle spasm, pain, tissue adherence or contracted tissue and/or soft tissue swelling, inflammation, or other cause of soft tissue or joint restriction.

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When do you use a PT re-evaluation code?

Under Medicare guidelines, a re-eval is medically necessary (and therefore payable) only if the therapist determines that the patient has had a significant improvement, or decline, or other change in his or her condition or functional status that was not anticipated in the POC (emphasis added).

Can 97164 and 97535 be billed together?

Yes, you are permitted to bill 97530 with 97164 if you use the 59 modifier/X modifier. If you do not bill with the appropriate modifier, then 97164 (Column Two code) will be denied. (See question 5).

Is PT re-eval a timed code?

This is not a timed code. The AMA CPT Assistant, which provides explanations of how CPT codes should be used, includes the following example of a PT re-eval: A 62-year-old male with low back pain presents for a physical therapy re-evaluation on his eighth visit of his episode of care.

Can 97164 and 97110 be billed together?

That's because CMS—at the behest of the APTA—has agreed to accept these pairs without the use of a modifier. In other words, you can perform the following services—and receive payment for them—without needing to affix modifier 59: 97110 with 97164. 97112 with 97164.

Does 97535 need a modifier?

Does CPT Code 97535 Need A Modifier? Yes, CPT 97535 requires Modifier 59 when two codes are billed individually on the same day.

What modifier is needed for 97164?

This payment policy requires that each new PT evaluative procedure code – 97161, 97162, 97163 or 97164 – to be accompanied by the GP modifier; and, (b) each new code for an OT evaluative procedure – 97165, 97166, 97167 or 97168 – be reported with the GO modifier.

How do you code a physical therapy evaluation?

Three codes — 97161, 97162, and 97163 — are used for physical therapy evaluation.

What is the CPT code for physical therapy re-evaluation?

For PT, the new re-evaluation code is 97164 (Reevaluation of physical therapy established plan of care) and will require these components: An examination including a review of history and use of standardized tests and measures; and.

What is the difference between 97161 97162 and 97163?

The new PT codes are: 97161- Low Complexity Evaluation; 97162- Moderate Complexity Evaluation; 97163- High Complexity Evaluation; 97164- PT re-evaluation. Each evaluation level has certain components and are different between PT and OT. PT has four components to each evaluation code and OT has three.

Can CPT code 97110 and 97140 be billed together?

Can CPT Code 97110 And 97140 Be Billed Together? Yes, they can be billed together. CPT 97110 and CPT 97140 can be performed on same day for same patient; instead, it is very common practice to use these codes together on same day.

What modifier should be used with 97110?

The CQ modifier does apply to 97110 because the PTA furnished all minutes of that service independently.

Can 97162 and 97140 be billed together?

As of January 1, 2020, the National Correct Coding Initiative (NCCI) has stated that if you bill an initial evaluation code (97161, 97162, 97163) or a re-evaluation code (97164) on the same date of service for the same patient as CPT code 97140 (Manual therapy), you MUST affix modifier 59 to 97140 in order to receive ...

What is the RE-EVALUATION OF PHYSICAL THERAPY ESTABLISHED?

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; 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.

What is the RE-EVALUATION OF OCCUPATIONAL THERAPY?

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; AND 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.

What is a high complexity physical therapy?

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.

What is a low complexity physical therapy evaluation?

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; AND 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.

What is a low complexity evaluation?

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; AND 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 ASSESSMENT (S) IS NOT NECESSARY TO ENABLE COMPLETION OF EVALUATION COMPONENT. TYPICALLY, 30 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY.

Can you use CPT in Medicare?

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials of CMS internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Why do contractors need to specify revenue codes?

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

What chapter is the musculoskeletal system code?

Additionally, there are several therapy-related codes in Chapter 13 : Diseases of the musculoskeletal system and connective tissue. Most of these codes have site and laterality designations to describe the bone, joint, or muscle related to the patient’s condition.

How do I code for surgical aftercare?

For example, you could use Z51.89, encounter for other specified aftercare, or Z47.1, aftercare following joint replacement surgery. However, as this article notes, “you should not submit Z51.89 as a patient’s sole diagnosis—if you can help it—because on its own, this code might not adequately support the medical necessity of therapy treatment. Thus, using it as a primary diagnosis code could lead to claim denials.” In fact, whenever you use an aftercare code, you also should code for the underlying conditions/effects. For chronic or recurrent bone, muscle, or joint conditions, check out Chapter 13.

What is the history of ICD-10?

The World Health Organization (WHO)—the public health sector of the United Nations that focuses on international health and outbreaks—started developing the ICD-10 coding system in 1983, but didn’t actually finish it until 1992. Yes, it took almost a decade to create ICD-10, and it has taken more than a decade for the US to actually put the final version of the code set to use.

Why ICD-10?

So, what about ICD-10 makes it so much better than ICD-9? Well, the massive number of codes means that medical providers—including rehab therapists—can more accurately document clinical information, including patient diagnoses. Ultimately, that fosters:

How do I use multiple ICD-10 codes for a single condition?

There, you’ll find directives such as “Use additional code” or “Code first” (“Code first” indicates you should code the underlying condition first). Also, keep in mind that there are single combination codes (i.e., one code that indicates multiple diagnoses) you can use to classify conditions that often occur simultaneously.

What are unspecified codes?

Unspecified codes are available for the rare cases in which there is absolutely no other, more specific option. If a more specific option is available, you should use it.

Does ICD-10 change my documentation?

The short answer is “no.” Sure, ICD-10 helps healthcare providers better communicate detailed diagnostic information through codes. However, codes aren’t enough by themselves; providers must also continue to complete detailed documentation to support their code selection. According to CMS, “If complete information is not captured in clinical documentation, the result will be incomplete documentation for coding that then can impact revenues through delays, missed revenues, [and] outcome measures that don’t clearly or accurately reflect the quality and complexity of the care that is being delivered.”

What is the CPT code for PT/OT?

Four of the most common PT/OT treatment modalities are represented by CPT® codes 97110, 97112, 97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes, and 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. These codes are sometimes referred to as therapy’s “Core Four:”

How often do you need to report a time based therapy code?

Time-based therapy codes require the provider to have direct contact with the patient, and are reported once for each 15 minutes of service . One-on-one contact is defined as “the provider is required to maintain visual, verbal, and/or manual contact with the patient.”

What is CPT coding?

CPT® coding for therapy consists of codes for evaluations, re-evaluations, and treatment. CPT® introduced new therapy evaluation and re-evaluation codes effective Jan. 1, 2017.#N#CPT® code descriptors for PT and OT evaluative procedures include specific components required for reporting, as well as the corresponding typical face-to-face times for each service. These evaluation codes require assigning a low-, moderate-, or high-complexity level to the therapy evaluation.#N#Each of the following components, noted in the code descriptors, must be documented to report the selected level of PT evaluation:

What are the components of occupational therapy?

Each of the following components, noted in the code descriptors, must be documented to report the selected level of OT evaluation: 1 Occupational profile and client history (medical and therapy) 2 Assessments of occupational performance 3 Clinical decision-making 4 Development of plan of care

How long is a therapist's treatment at 8 a.m.?

Example: At 8 a.m. the therapist provides seven minutes of treatment described by code 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility; at 8:15 a.m. the therapist provides 23 minutes of treatment described by code 97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities; and at 8:45 a.m. the therapist provides another eight minutes of treatment described by code 97110.

What is 97140 code?

Code 97140 reports the provision of manual (soft tissue and joint) therapy techniques for treatment of symptoms and impairments that might include limited range of motion, muscle spasm, pain, tissue adherence or contracted tissue and/or soft tissue swelling, inflammation, or other cause of soft tissue or joint restriction. As the code descriptor states, “manual” therapy requires providers to use their hands to provide these techniques. Manual therapy techniques may include soft tissue mobilization, joint mobilization and manipulation, manual lymphatic drainage, manual traction, craniosacral therapy, myofascial release, or neural gliding techniques.

How many minutes of therapy is required for a treatment?

The therapy treatment documentation must include the total number of minutes spent treating the patient for each modality or the beginning and end times of each treatment. At least eight minutes of therapy must be performed to charge for one unit of any of the time-based codes.

What is 97164 in a re-evaluation?

Use: Re-evaluation (97164) This could include any improvement, decline, or other change in functional status that: you didn’t anticipate when you originally established the plan of care, and. requires further evaluation to ensure the best therapy outcomes.

How long does it take for a patient to return to therapy?

This depends on a couple of factors. If the patient returns to therapy within 60 days to continue treatment for the same (or a related) condition, it would be appropriate to perform and bill for a re-evaluation. However, if the patient discontinues therapy for more than 60 days , you will need to perform and bill for an initial evaluation upon his or her return to care.

How often do you need to complete a progress note for Medicare?

For Medicare patients, you need to complete a progress note every 10 visits —not a re-evaluation. As for the plan of care, you can certify the plan of care duration up to 90 days (provided the patient's condition warrants it). If the patient requires care beyond 90 days, you would then need to recertify the plan of care with the physician after the original POC expires. I hope that helps!

What is 97164 in healthcare?

Use: Re-evalua tion (97164) If, during the course of care, you determine that the original plan isn’t having the intended effect on the patient, you may feel it necessary to change the plan of care. In this case, you would perform—and bill for—a re-evaluation.

What is 97164 in medical?

Use: Re-evaluation (97164) If you are treating a patient, and he or she presents with a second diagnosis that is either related to the original diagnosis or is a complication resulting from the original diagnosis, you’ll need to complete a re-evaluation and create an updated plan of care.

When a patient with an active plan of care presents with a second condition that is totally unrelated to the primary?

Conversely, when a patient with an active plan of care presents with a second condition that is totally unrelated to the primary issue, you should select the appropriate initial evaluation code. The nuance for therapists to remember is that a re-evaluation is triggered by a significant clinical change in the condition for which the original plan of care was established. The second, unrelated problem (i.e., with a different body part or body system) may not, in and of itself, result in a change to the original condition.

Is it appropriate to bill a re-evaluation at discharge?

It's typically not appropriate to bill a re-evaluation at discharge. Here's a quote from Noridian explaining why: "Routine re-evaluations of expected progression in accordance with the plan of care, either during the episode of care or upon discharge, are not considered to be medically necessary separately billable services." ( https://med.noridianmedicar... )

Where can I get an ICD-10 code book?

While you can access the entire code set free of charge here, you may find a PT-specific ICD-10 code book useful for educational purposes, as it likely will provide guidance around coding strategy and processes. We actually sell one in the WebPT Marketplace, so if you’re a Member, you can purchase it at a discounted price here. Otherwise, you can purchase it here.

What about the ICD-10 grace period?

There’s a lot of confusion regarding CMS’s “grace period.” According to CMS, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”

Do I have to use external cause codes?

As explained in this blog post, there’s no national requirement mandating any provider—PTs included—to submit external cause codes. However, providers are encouraged to do so when possible. Most of the PT-relevant codes that allow for external cause codes are located in Chapter 19 of the tabular list (which you can access here). Furthermore, some state and regional payers may require the use of external cause codes, so check with each one individually.

What if I don’t know what caused a patient’s injury or condition?

External cause codes are not mandatory (at least not nationally), and remember that you cannot code for what you don’t know. So, if you don’t know the details necessary to select external cause codes—like what caused the onset of the injury, the activity the patient was engaged in at the time of the injury, or where the patient was when the injury occurred—then don’t submit any such codes.

Should I start using ICD-10 codes now?

No. Payers will deny claims that contain ICD-10 codes prior to October 1, just like they’ll deny claims that contain ICD-9 codes after September 30.

Do I need to do a progress note, evaluation, or re-evaluation to switch to ICD-10 codes?

No, you do not. Instead, when it comes time to add ICD-10 codes for the patients who previously had ICD-9, you’ll simply update the diagnoses in the patients’ charts as they come in for appointments on or after October 1.

Will I need to mass-update my patient notes come October 1?

No, there’s no need for a sweeping code change for all your patient notes. You’ll simply update codes within patients’ charts as they come in for their visits. Or, if you are a WebPT Member, you can use the ICD-9 to ICD-10 Conversion Report to begin saving ICD-10 codes to current patient cases. Then, once October 1 hits, our system will automatically start sending ICD-10 codes—rather than ICD-9—through to your finalized notes.

What is re-evaluation documentation?

Re-evaluation documentation must include clear justification for the need for further tests and measurements after the initial evaluation, such as new clinical findings, a significant, unanticipated change in the patient’s condition, or failure to respond to the interventions in the plan of care. It is expected that clinicians continually assess the patient’s progress as part of the ongoing therapy services. This assessment is not considered a formal re-evaluation; the time of any assessment is included and billed within the appropriate treatment intervention CPT code.

How long is CPT time?

Many CPT codes for therapy modalities and procedures specify that direct (one-on-one) time spent in patient contact is 15 minutes. The time counted is the time the patient is treated using skilled therapy modalities and procedures, and is recorded in the documentation as “Timed Code Treatment Minutes.” Pre- and post-delivery services are not to be counted when recording the treatment time. The time counted is the “intra-service” care that begins when the qualified professional/auxiliary personnel is directly working with the patient to deliver the service. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment. The intra-service care includes assessment. The time the patient spends not being treated because of a need for toileting or resting should not be counted. In addition, the time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time. Time spent “supervising” a patient performing an activity that is defined as a timed code, or for the patient to perform an independent activity, even if a therapist is providing the equipment, is considered unbillable time and these minutes should not be counted in the “Timed Code Treatment Minutes.” Therapy timed services require direct, one-on-one patient qualified professional/auxiliary personnel contact, and by definition cannot be billed when performed in a supervised manner.

How often should a progress report be written?

Progress reports shall be written by a clinician at least once every 10 treatment days or at least once every 30 calendar days , whichever is less. Writing progress notes more frequently than the minimum is encouraged to support the medical necessity of treatment. A progress report is not a separately billable service.

What is the purpose of an initial evaluation?

The initial evaluation, which must be performed by a clinician, should document the medical necessity of a course of therapy through objective findings and subjective patient self-reporting. Documentation of the initial evaluation should list the conditions being treated and any complexities that make treatment more lengthy or difficult.

Why do contractors need to specify revenue codes?

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

What modifier is used for non-covered services?

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

Why is medical record required?

Medical record documentation is required for every treatment day, and every therapy service to justify the use of codes and units on the claim.

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ICD-10 Considerations

  • In therapy encounters, there is often more than one diagnosis in the treatment record or order. The primary diagnosis is the patient’s medical diagnosis such as a cerebrovascular accident (I63.9) or complete rotator cuff tear of the right shoulder (M75.121). The additional diagnoses, often referred to as the therapy diagnoses, are the conditions ca...
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Select An Appropriate Seventh Digit

  • Due to the nature of conditions and injuries that therapists treat, the seventh character definitions A (initial encounter), D (subsequent encounter), and S (sequela) frequently apply. The ICD-10 definition for initial encounter is not based on whether the provider is seeing the patient for the first time. When selecting the seventh character: Use A while the patient receives active treatme…
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Procedural Coding

  • CPT® coding for therapy consists of codes for evaluations, re-evaluations, and treatment. CPT® introduced new therapy evaluation and re-evaluation codes effective Jan. 1, 2017. CPT® code descriptors for PT and OT evaluative procedures include specific components required for reporting, as well as the corresponding typical face-to-face times for each service. These evalua…
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Four Codes Represent CORE Modalities

  • Four of the most common PT/OT treatment modalities are represented by CPT® codes 97110, 97112, 97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes, and 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance…
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