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New Evaluation Codes for OT in Medicare Physician Fee Schedule Proposed Rule


7/8/2016

On July 7, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that updates payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS), effective January 1, 2017. New occupational therapy CPT evaluation and re-evaluation codes are being proposed under the Physical Medicine and Rehabilitation section of the CPT Manual to replace existing CPT codes 97003 and 97004. The coding paradigm for evaluations is based on patient complexity (low, moderate, or high) and reflects the multi-year work of AOTA with the American Medical Association’s CPT Editorial Panel and Relative Value Scale Update Committee (RUC). 

Why are there new evaluation CPT codes? Get answers to your coding questions here

CMS proposes a work relative value unit (RVU) of 1.20 for each of the OT evaluation CPT codes, rather than differing values per code, due to its concerns with potential abuses and budget neutrality. The work RVU is a component that is taken into account for the valuation of the full price of CPT codes based on the work of the therapist and includes the time to perform the service, technical skill and physical effort, required mental effort and judgment, and stress due to potential risk. This RVU is consistent with the long-standing value for the current evaluation code (97003). CMS proposes a work RVU of .60 for the re-evaluation code, which is consistent with the current value of 97004. The new occupational therapy evaluation codes and descriptors are set forth in the Table below. 

In addition to occupational therapy evaluation and re-evaluation code changes, CMS makes the determination in the proposal that it is not within the agency’s authority to add occupational therapy, physical therapy, or speech-language pathology services to the list of Medicare recognized telehealth services, stating that new legislation will be required to add therapists to the list of practitioners who can report telehealth services. CMS proposes several new policies designed to improve Medicare access and payment for patients with multiple chronic conditions, mental and behavioral health issues, and cognitive impairments, including changes to the Chronic Care Management & Transitional Care Management CPT codes. CMS also proposes changes to the Medicare Shared Saving Program governing Accountable Care Organizations.

AOTA staff is closely reviewing the proposed rules and will provide a detailed analysis regarding the implications for occupational therapy shortly. These proposals are subject to public comment through September 6, 2016, with a final rule expected to be published in November 2016 finalizing the code descriptors, values, and Medicare policies effective January 1, 2017. 

AOTA requests that members review the new codes and policies and send any feedback or concerns to regulatory@aota.org. Members can also submit comments to CMS directly beginning July 15.

The display copy of the PFS proposed rule can be found here. Please refer to pages 342–352 for relevant information on the updated occupational therapy codes.


New CPT Code

Proposed CPT Long Descriptors for Physical Medicine and Rehabilitation

97X65

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 (i.e., 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 (e.g., 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.

97X66

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 (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
● 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 (e.g., 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.

97X67

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 identify 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and ● A clinical decision-making is 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 presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., 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.

97X68

Reevaluation 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.

Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year (CY) 2017.  Page 350. https://federalregister.gov/a/2016-16097