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Why Are There New Evaluation CPT Codes? Answers to Your Coding Questions

AOTA Staff
7/25/2016

Why are there new codes? Where did the new codes come from?

AOTA has been involved in a process to review and revise a number of CPT codes used by occupational therapists for several years due to the fact that a subset of the Physical Medicine and Rehabilitation (PM&R) codes are viewed by the Centers for Medicare & Medicaid Services (CMS) as high utilization codes. As part of this process, AOTA conducted a full review of all codes reported by occupational therapists and determined that many codes, including the evaluation (97003) and re-evaluation (97004) codes, have not been altered in almost 20 years and required revision to reflect contemporary OT practice.

This revision is a multi-year AOTA effort with the American Medical Association’s (AMA’s) CPT Editorial Panel and Relative Value Scale Update Committee (RUC). Per AMA confidentiality rules, AOTA has not been allowed to publicize the details of our work with the evaluation codes to our members until now, with the recent release of the Medicare Physician Fee Schedule proposed rule. AOTA staff and occupational therapy practitioners played an integral role in this major coding revision process, bringing to the table their coding and OT expertise.

How did AOTA help develop the new evaluation and reevaluation codes?

AOTA, along with representatives from other specialties, participated on an AMA PM&R Workgroup and played an integral role during all discussions about revisions to these codes. AOTA provided specific wording for the coding descriptors that ensured that occupational therapy’s distinct value was captured in the updated code descriptors. Ultimately, AOTA proposed a tiered coding and valuation structure that accounted for complexity in the evaluation code descriptors (low, medium, and high) through the addition of clinical factors that must be considered as part of each initial evaluation.

How are the new codes better than the existing CPT codes 97003 and 97004?

The new coding paradigm for evaluations is based on patient complexity (low, moderate, or high). AOTA believes that this shift in coding addresses the needs of a radically different health care population than that which existed when these codes were originally developed in 1997. Occupational therapy practice is moving to meet the needs of both the aging and pediatric populations experiencing increasing cognitive, physical, and psychosocial problems, and who have an expectation for high-quality services and beneficial outcomes.

Why are the evaluation codes valued the same?

AOTA presented to the AMA our recommended code values for the OT evaluation codes and those recommendations were sent to CMS. CMS released a proposed rule on July 7 that included the values for the codes.

CMS proposed 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 like upcoding. CMS also wants to achieve budget neutrality, meaning that Medicare costs should not go up as a result of the AMA code change process. AOTA believes in and advocated for codes that are priced according to complexity based on the varying clinical and analytical work involved; however, CMS decided to value the evaluation codes as a group, rather than tiered individually.

Why do we need to indicate levels of patient complexity if the codes are valued the same?

Education is key, and AOTA will be working to educate occupational therapy practitioners on the importance of accurately differentiating the levels contained in the three evaluation codes and accurately documenting the low-, moderate-, and high-complexity evaluations appropriately, even though the codes have been given the same value for CY2017. CMS has indicated that it will analyze the utilization of the different levels and will make value determinations based on that data. We believe that having an accurate reflection of the use and utilization of these codes will help us later advocate for different values.

Education and correct code selection and documentation in the medical record will be critical in calendar year 2017 to demonstrate to CMS the true utilization of and need for evaluation codes with differing complexity levels. For this reason, AOTA is looking to help support the profession through education to choose and document these codes correctly based on levels, despite the values being the same in 2017.

What is AOTA preparing to do next?

We are here to help you prepare for this significant change! AOTA is now beginning to educate members about the new codes, including coding presentations through AOTA CE webinars, articles, and presentations at state and specialty conferences this summer, fall, and winter.

AOTA is in the process of closely reviewing the proposed rule and will release a detailed analysis of how the rule will affect occupational therapy to AOTA members. AOTA is also preparing comments to submit to CMS by the September 6 comment deadline. We expect the final rule to be published in November, which will contain the final code descriptors and values that would be effective on January 1, 2017.

What should I do if I’m concerned about the new codes?

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 here.