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Joined: Wed Jun 06, 2018 2:47 pm

Wed Jun 06, 2018 3:13 pm

Hi there,
I am new to auditing for our PT/OT/SLP clinic and I have a few questions.

1) can someone please better define the different between low, moderate and high complexity in the new OT evaluation codes 97165-97167 and the new PT eval codes 97161-97163? I have done some extensive research and I am finding that this is up to the interpretation of the therapist after the evaluation process, however the Therapists are not sure how to interpret the different levels. how can I explain this to them?

2) my OT's and PT's seem to think (as they have been told in the past) that the diagnosis they should be using when submitting their bills is the diagnosis that was submitted on the referral. I have advised them that they should be documenting and using the diagnosis for what THEY are treating them for. EXAMPLE: patient's referral states Autism, however the PT is treating them for torticollis. would you agree that they should be using the diagnosis of Torticollis for their treatment?

thank you!
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Mon Jun 25, 2018 11:13 am


I went back to my information from AMA-CPT for 2017, which is the year in which these codes were created. When considering the level of initial evaluation, it is best to break it down into different levels (which, granted, is a new proposition to therapists who have never had to deal with E/M-like services).

CPT code 97161 would be for a patient with no personal factors or comorbidities, an examination of only 1-2 elements among the following: Body structures & functions, activity limitations and /or participation restrictions), stable or uncomplicated presentation and low complexity clinical decision making. Typically takes 20 minutes of face-to-face time;

CPT code 97162 would be for a patient with 1-2 factors or comorbidities, examinations of body systems including all three of the factors above, a variance of characteristics upon presentation, and moderate complexity clinical decision making. Typically, 30 minutes of face-to-face time;

CPT code 97163 would be for a patient with 3 or more factors or comorbidities, a complex exam of multiple body systems, unstable presentation and unpredictable characteristics and high complexity medical decision making. Typically 45 minutes of face-to-face time.

Bear in mind that the presentation of the patient will more than likely be the driving factor in complexity of the visit. For occupational therapy evaluation codes 97165 thru 97167, the assessments should include varying degrees of performance deficits. The times for these codes are 30, 45 and 60 minutes, respectively.

In the second example below, the presentation points to moderate complexity due to the comorbidity of autism, but it is indeed true that the torticollis is what is being treated, and should be indicated as what is being treated. In the case where a diagnosis comes over on a referral that would quite obviously not be the focus of treatment, it might be helpful to question the referral prior to treatment.

Your question has been answered by J. Paul Spencer, CPC, COC
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