2. 2017 Physical Therapy Evaluation Codes Train-the-Trainer Slide Deck
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AMA’s 2017 Current Procedural Terminology (CPT®) manual contains 4 new codes that describe and report physical therapy evaluations. There also are new codes to describe occupational therapy evaluations and athletic training evaluations, for a total of 12 new evaluation code descriptors in the physical medicine and rehabilitation code family (97000 series). These new codes replace the previous codes that were reported to describe PT, OT, and AT evaluations (97001 through 97006, respectively).
Medicare added the new evaluation codes to the 2017 Medicare physician fee schedule (MPFS), making them reportable on claims for Medicare beneficiaries under the respective therapy benefits. Commercial payers who are required by the Health Insurance Portability and Accountability Acct (HIPAA) to use a standardized codes set (CPT) in their claims process must use the most current version of CPT, which will include these new codes. HIPAA does not apply to workers’ compensation or auto liability payers, although as seen with the transition to ICD-10, many of these payers also tend to use updated codes when they are permitted. We will discuss the PT evaluation codes in depth from both a reporting perspective (documentation to support the evaluation) and from a payment perspective (how these new codes will be valued and paid under the Medicare fee schedule, and potentially by other payers).
In summary: What will the new evaluation codes do?
Replace existing CPT codes (physical therapy evaluation) and (physical therapy reevaluation).
Apply to claims for covered services provided to Medicare beneficiaries, as well as to other payers subject to HIPAA requirements.

3. INTRODUCTION
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Welcome to this facilitator training for the New Evaluation Codes.
The New Evaluation Codes slide deck is a 6-session curriculum designed to provide information and additional clarity regarding the new evaluation codes.

4. Training Agenda
Part I: Introduction
Part II: PT evaluation code descriptors
Part III: Defining the evaluation process
Part IV: Payment for new evaluation codes
Part V: Resources
Part VI: Clinical scenarios and suggested coding
©2017 American Physical Therapy Association. All rights reserved.
The training agenda is divided up in to 6 parts meant to familiarize new facilitators with the curriculum content and framework, as well as help new facilitators become familiar with the framework of the new evaluation codes.
Part I: Introduction
A brief overview of the importance of the PT evaluation and what you can expect to learn in today’s agenda, including a review of the learning objectives for facilitators.
Part II: PT evaluation codes descriptors?
An in depth description of the evaluation codes nomenclature.
Part III: Defining the evaluation process
A description of the evaluation process and definitions of key terms.
Part IV: Payment for new evaluation codes
Tips and information from Medicare and third-party payers regarding reporting and payment of the new codes.
Part V: Resources
List of resources used to assist with additional clarification.
Part VI: Clinical scenarios and coding
Various scenarios by specialty to assist with coding for services.

5. Training Learning Objectives
1. Explain why changes were made to PT evaluation codes
2. Identify the new language and structure of the evaluation and reevaluation codes
3. Describe the components that determine differences between complexity levels of the evaluation codes
4. Determine the appropriate evaluation code for several patient scenarios
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This agenda was designed to meet 4 key learning objectives:
Explain why this change to the structure and language of the physical therapy evaluation codes was made to the AMA CPT code set.
Identify the new language (coding nomenclature) and structure for reporting physical therapy evaluations and reevaluations.
Describe each required component that informs the level of complexity the therapist reports to describe their patient’s evaluations.
Assign complexity levels to patient scenarios, demonstrating a practical understanding of the process for assigning the best code for each patient’s evaluation.

6. Physical Therapy Evaluation Code Descriptors
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7. The Importance of the Physical Therapist Evaluation
The evaluation drives the care and/or management of the care.
A thorough and complete evaluation is critical to success in achieving a positive outcome for the patient’s episode of physical therapist care.
A reflection of the level of complexity of the patient is key to effective management throughout the episode.
©2017 American Physical Therapy Association. All rights reserved.
Before we jump into the overview of the code descriptors, it is helpful to reflect on the importance of your evaluation to the overall episode of care provided to your patient, and the importance of reporting your evaluations in a manner that reflects your level of clinical decision making.
First contact with a patient, and the information collected and documented, drives the management of your patient’s plan of care. Effective management throughout the episode of care is founded in sound clinical decision making and is the hallmark of a doctoring profession.
A thorough evaluation that culminates in a clear and concise plan for managing the patient’s condition over the episode of their care is critical to achieving a positive outcome for the patient and ultimately for the entire episode of care for the patient’s condition. This includes communication that is consistent and easily understood.
The evaluation should be a reflection of the value your clinical decision making brings to the health care needs of your patient, as well as to any other qualified health care providers involved in your patient’s care.

8. Elements of a Physical Therapist Evaluation
Consistent with APTA’s Guide to Physical Therapist Practice
Examination (includes history, systems review, and tests and measures)
Evaluation (the thought process leading to identifying impairments, functional limitations, disabilities, and needs for prevention)
Diagnosis (impact of the condition on function)
Prognosis (professional judgment regarding the predicted functional outcome and the estimated duration of services required)
Plan of Care (the culmination of an evaluation)
©2017 American Physical Therapy Association. All rights reserved.
Terminology in the Guide to Physical Therapist Practice is consistent with the approach these codes reflect in describing the elements of an evaluation:
Examination
History (medical and functional)
Systems review to rule out problems that may or may not be related to the chief complaint, may impact the plan of care, and may require consultation with others
Tests and measures: objective information used to prove or disprove the hypothesized diagnosis(es) and reflect a benchmark that can be retested to mark progress or lack of the same
Evaluation – critical thinking and decision making
Synthesizes data to inform development of a plan for care.
Guides the diagnosis and prognosis, and drives the plan of care, which is a reflection of the PT’s clinical decision making.
PTs NEED codes that reflect how these elements in our description of practice change given the complexity of the patient being evaluated.
The plan of care includes coordination, consultation, and collaboration of care with physicians and other providers or agencies.

9. 2017 Physical Therapy Evaluation Codes
The objective for changes to the evaluation codes:
Facilitate a payment method based on the accurate and complete communication of the following:
Completed patient assessment instrument
Evaluation of clinical presentation
Treatment and management options planned and provided
Demonstration of value associated with achievement of functional outcomes
Payment Based on Quality and Outcomes = Value to Patient and the Payer
©2017 American Physical Therapy Association. All rights reserved.
The objective for changes to the evaluation codes was to facilitate a payment method based on the accurate and complete communication of the following:
PTs are encouraged to use patient assessment tools and instruments as much as possible.
The clinical presentation is better communicated through the documentation of required elements.
Identifying the patient’s level of complexity assists in the development of an appropriate plan of care.
The value of our services will be better demonstrated through the use of functional assessment tools at the time of the initial evaluation, interim reporting as the patient is treated, and then reporting the achievement of functional outcomes at the end of that episode of care.
Overall, payment will be based on quality and outcomes, which equals value to the patient and the payer.
Change to structure and language of codes reflects growth of the practice of physical therapy.

10. 2017 Physical Therapy Evaluation Codes
3 Evaluation Codes (97161, 97162, and 97163)
Low complexity, moderate complexity, high complexity
Components:
Patient history (comorbidities, personal factors),
Examination and the use of standardized tests and measures,
Clinical presentation, and
Clinical decision making
1 Reevaluation Code (97164)
Performed when an established patient is being evaluated to update a plan of care
All incorporate use of standardized tests and measures and patient assessment instruments or functional outcome measures
©2017 American Physical Therapy Association. All rights reserved.
Here are the code numbers and short descriptors published in the 2017 AMA coding manual, and we’ll go into the introductory language and long descriptors further in this training module. All are licensed by the AMA.
The initial evaluation comprises 3 codes representing low, moderate, and high complexity. Each level of complexity has 4 components: patient history, examination, clinical presentation, and clinical decision making. Later in this training module we’ll go into further details regarding each of these components.
The reevaluation code is not described by complexity, but instead is reported when an established patient is being evaluated to update their plan of care due to significant progress or lack of progress, or at the end of the episode of care when specific recommendations are made for the patient’s continued management or the patient is referred to another provider. Reevaluations are described by a single level that reflects an established plan of care.
Use of standardized tests and measures, functional assessment tools, and outcome measures help to support the examination and clinical decision making in context of the patient’s history and clinical presentation.
Although clinical decision making is represented as a fourth bullet to be documented, it actually represents the process of considering the history, clinical examination, and clinical presentation to determine the level of complexity. Incorporating patient assessment instruments facilitates, and gives some objective support to, the element “clinical decision making.”
Beginning January 1, 2017, these codes will need to be reported to Medicare and other third-party (commercial) payers that either pay under the Medicare fee schedule or are required to use the standardized code set under HIPAA regulations. Payers representing workers’ compensation and auto liability claims are not bound by HIPAA to use the most recent CPT codes and therefore have the option of continuing to report using the codes and

11. 97161 – Physical Therapy Evaluation: Low Complexity
History
Examination
Presentation
Decision-Making
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.
©2017 American Physical Therapy Association. All rights reserved.
Let’s pull all of these elements of the evaluation together and review the CPT nomenclature. The AMA language for low, moderate, and high complexity is shown in the next 3 slides and includes all the elements that must be supported to be able to report each level of evaluation. At a minimum, each of these components must be supported by the documentation of the 4 elements of the evaluation.
Low complexity is demonstrated by a history with no personal factors and/or comorbidities that have an impact on the PT plan of care.
The exam reflects 1 to 2 elements of any of the body structures and functions, activity limitations, and/or participation restrictions. For example, a patient found to have limitation in self-care (hygiene/dressing) and lack of ROM in the knee due to edema and joint stiffness would reflect 2 elements.
The patient’s presentation is stable or uncomplicated (unchanging).
The clinical decision-making component is supported by the use of a standardized patient assessment tool and/or measures reflecting the aspects of function that will be included in the goal setting for this patient (eg, LEFS, Womac, Lysholm).

12. 97162 – Physical Therapy Evaluation: Moderate Complexity
History
Examination
Presentation
Decision-Making
A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;
An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
An evolving clinical presentation with changing characteristics; and
Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
©2017 American Physical Therapy Association. All rights reserved.
Moderate complexity is demonstrated by a history with 1 to 2 personal factors and/or comorbidities that have an impact on the PT plan of care.
The exam reflects 3 or more elements of any of the body structures and functions, activity limitations, and/or participation restrictions.
The patient’s presentation is evolving (changing).
The clinical decision-making component is supported by the use of a standardized patient assessment tool and/or measures reflecting the aspects of function that will be included in the goal setting for this patient.

13. 97163 – Physical Therapy Evaluation: High Complexity
History
Examination
Presentation
Decision-Making
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.
©2017 American Physical Therapy Association. All rights reserved.
High complexity is demonstrated by a history with 3 or more personal factors and/or comorbidities that have an impact on the PT plan of care.
The exam reflects 4 or more elements of any of the body structures and functions, activity limitations, and/or participation restrictions.
The patient’s presentation is unstable and unpredictable.
The clinical decision making component is supported by the use of a standardized patient assessment tool and/or measures reflecting the aspects of function that will be included in the goal setting for this patient (eg, LEFS, Oswestry, Neck Disability).

14. 97164 – Physical Therapy Re-evaluation: Established Plan of Care
Requires an examination including a review of history and use of standardized tests and measures; and
Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome
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The reevaluation describes the reexamination of the patient and any revision of the plan of care, such as duration, area being treated, and long-term goal revision.
Reevaluation must include the elements listed in the code descriptor, including the use of a standardize patient assessment instrument and/or measurable assessment of functional outcome.

15. 2017 Physical Therapy Evaluation Codes: Typical Time Spent
97161: Low Complexity
97162: Moderate Complexity
97163: High Complexity
97164: Reevaluation
Typically, 20 minutes are spent face-to-face with the patient and/or family.
Typically, 30 minutes are spent face-to-face with the patient and/or family.
Typically, 45 minutes are spent face-to-face with the patient and/or family.
©2017 American Physical Therapy Association. All rights reserved.
The evaluation and reevaluation codes are considered service-based codes, they are not time-based codes and are not paid based on units of time.
The “typical times” described in AMA’s CPT descriptors for these codes provide guidance for thoroughly describing the evaluation service. The typical time stated for each code is not the determining factor in selecting the complexity level. The key elements documenting the complexity of the initial evaluation determines which level of code is selected.
Bottom line: Time for the evaluation should not be used as a factor in determining levels.
They are general guidelines representing the typical face-to-face time the PT or OT spend with the patient during the evaluation process. The key components that determine the level of complexity for the evaluation service include the previously discussed criteria of history, physical exam, clinical presentation, and using clinical judgment to communicate the selected complexity. Because these typical times are for guidance only, make sure your documentation of all the components of evaluation support complexity level you select.
Consider this example: An evaluation of a patient takes 45 minutes, and after considering all the key elements the PT selects low complexity (97161), even though 45 minutes is the “typical time” for a high-complexity evaluation. The clinician should document the reasons for the additional time, to help confirm that he or she selected the correct level for that evaluation.

16. Reporting a Therapy Diagnosis and Reporting Level of Patient Complexity
Establishing a therapy diagnosis and
Considering of a patient’s medical comorbidities, functional history, and other personal factors
Demonstrates the value of the clinical decision making required to provide medically necessary care.
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The PT determines what it is he or she is going to treat (the therapy diagnosis) based on the examination.
The PT acknowledges patients in context with their comorbidities, previous functional level, potential for functional return, and any other personal factors.
The tiered coding structure places value and greater emphasis on the PT’s clinical decision making.

17. Describing the Evaluation Process and Defining Terms for Reporting Evaluation Codes
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18. Introductory Language
“Physical therapy evaluations include: patient history, and an examination with the development of a plan of care....which is based on the composite of the patient’s presentation.”
“Coordination, consultation, and collaboration of care with physician, other QHP, or agencies is provided consistent with the nature of problem(s) and the needs of the patient, family, and/or other caregivers.”
©2017 American Physical Therapy Association. All rights reserved.
This slide depicts the actual language in the AMA CPT manual introduction. To reiterate: Physical therapy evaluations culminate in the development of a plan of care for the patient that reflects all aspects of the evaluation process including patient history and examination. It is informed by the patient’s clinical presentation and the therapist’s clinical judgment.
Documentation should reflect that the coordination, consultation, and collaboration of care with the physician, other qualified healthcare provider (QHP), or agencies is provided consistent with the nature of the problem(s) and the needs of the patient, family, and/or other caregivers.

19. Introductory Language (continued)
At a minimum, each of the following components noted in the code descriptors must be documented, in order to report the selected level of complexity for an evaluation.
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This statement is reflected in the introductory language and provides additional guidance for coding a physical therapy evaluation. As we begin to define terms, describe processes, and review examples of the application of these evaluation codes, keep in mind the aspect of communicating this information in a clear, concise, and consistent manner.

20. Introductory Language (continued)
Physical therapy evaluations include the following components:
History
Examination
Clinical decision making
Development of plan of care
©2017 American Physical Therapy Association. All rights reserved.
These are the components that are noted in the introductory language, which are highlighted here because they differ from the actual code language, which this presentation will discuss in more depth as we continue.
Missing from this list is the patient’s “clinical presentation,” which was noted earlier as a component of the new codes. In addition, included as the fourth bullet here is “development of the plan of care,” which differs from the code descriptor language that describes “clinical decision making” and “using a standardized patient assessment instrument and/or measurable assessment of functional outcome,” which culminate in the development of the plan of care.
Why is the introduction stated differently from the code descriptor? The purpose of the introductory language is to provide guidance from the overall perspective of the evaluation process, while the code descriptors are more specific regarding the actual elements of documenting the evaluation process.

21. Code Descriptor Language
4 primary elements that will inform selection of evaluation complexity level:
History
Examination
Clinical presentation
Clinical decision making, leading to the development of a plan of care
Must communicate information regarding all 4 elements
All 4 elements must support the selected complexity level
©2017 American Physical Therapy Association. All rights reserved.
You must address 4 primary elements in your documentation to support the level of complexity you have selected.
1. Patient history
2. Physical exam
3. Description of patient’s clinical presentation
4. Your clinical decision making, which is basically pulling it all together to describe the complexity level and inform your plan of care
These 4 elements are included in the descriptors of the new evaluation codes published in the AMA CPT manual, and we’ll go through each of them so you can understand the documentation elements.

22. The Evaluation Process
Process: A physical therapy evaluation includes determining the patient’s overall severity and complexity:
History (medical and functional) and impact of “contextual factors”
Examination
Body structures and functions
Activity limitations and/or participation restrictions
Environmental and personal factors
Leads to ability to describe clinical presentation; and
Leads to ability to make clinical judgments to develop a plan for managing the patient through an episode
©2017 American Physical Therapy Association. All rights reserved.
The evaluation process follows certain steps that will result in the most appropriate plan for care!
History includes medical aspects (comorbidities), functional aspects (prior level), and contextual factors that include personal factors and environmental factors.
In the examination portion these factors can be measured and clarified for impact using standardized tests and measures as described in the Guide to Physical Therapist Practice.
This is followed by assessment of the patient’s clinical presentation and clinical decision making ability to determine their complexity level and management through your plan of care.
To review, physical therapy evaluations include the following components: history, examination, clinical decision making, and development of plan of care. The plan of care reflects medical necessity for care and encompasses treatment interventions selected to address patient needs to related injury, illness, and condition; recognition of comorbidities or other issues that may affect length or frequency of care; and the determination of frequency and duration of care.

23. Clinical Decision Making
History
Comorbidity and personal factors that impact the plan of care
Examination
Body systems: structures and functions
Activity limitations and/or participation restrictions
Clinical Presentation
Stable, Evolving, Unstable
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Evaluation complexity: low, moderate, or high
97161, 97162, 97163
This slide provides a visual example of what we’re discussing regarding the relationship of elements of the evaluation. The history, examination, and clinical presentation all inform your clinical decision making, leading to the importance of understanding all the elements of the evaluation process. You will need to review and potentially adapt your process of performing and documenting patient evaluations in light of the new codes. Because the stratified levels require that you differentiate the complexity of your evaluations, your evaluation process will need to facilitate choosing the code that best represents each patient’s evaluation.

24. Patient History
IF IMPACT on PLAN OF CARE: Assists in supporting level of evaluation:
Comorbidities that impact function and ability to progress through a plan of care
Previous functional level; context of current functional abilities
Past treatment approaches, if applicable, and other factors that may impact patient’s ability to progress and reach goals
Include other contextual factors as applicable
Personal factors
Environmental factors
©2017 American Physical Therapy Association. All rights reserved.
The way you document your patient’s history may need to be updated since this information now will help you determine the level of complexity involved in the evaluation and treatment of your patients.
The patient history includes previous medical conditions and comorbidities; previous functional level; context of current functional abilities, treatment approaches in past, if applicable; and other factors that may impact the patient’s ability to progress and reach goals as stated in the plan of care. The history and interview process may also include the patient’s work status, impact of medications, and other clinical tests.

25. Documenting Patient History: Defining Contextual Factors
Personal Factors influence how disability is experienced by the individual:
Include sex, age, coping styles, social background, education, profession, past/current experience
Overall behavior patterns, learning styles, adherence to interventions
Personal factors that exist but do not impact the physical therapy plan of care are not to be considered when selecting a level of service.
Environmental Factors
Physical, social, and attitudinal environment in which people live and experience
©2017 American Physical Therapy Association. All rights reserved.
Part of describing a patient’s history is documenting any contextual factors that may impact the plan of care. Personal and environmental factors provide additional context to your patient’s presentation and could impact how the patient responds to the plan that is developed based on your evaluation. You may recognize these terms, and others that we also will discuss, because they are described within the International Classification of Functioning, Disability and Health (ICF) and reflect ICF’s standard language and framework for the description of health and health-related states. APTA formally endorsed the ICF framework in 2008 and adopted the framework in Guide to Physical Therapist Practice 3.0.
Personal factors include sex, age, coping styles, social background, education, profession, and past and current experience.
Important to note: You might identify personal factors for which you cannot ascribe an impact on the patient’s plan of care. Do not include these factors in your decision related to the complexity of the evaluation.
Environmental factors are those that may either facilitate or present barriers to the plan of care. Examples include ground texture or condition that will affect balance, noise that could affect hearing and understanding, and distractions that could affect learning.

26. Documenting Examination
Components of Examination
Body structures and functions: Impairment resulting in limits in function resulting in presenting condition
Activity limitations and/or
Participation restrictions
Environment (facilitator - support systems, barrier- physical characteristics)
©2017 American Physical Therapy Association. All rights reserved.
Here is a summary of the components of the physical examination portion of the physical therapy evaluation. Like “personal factors” and “environmental factors,” these are ICF terms, which more clearly represent what a physical therapist addresses in the evaluation and treats as part of the plan of care.
The more you can familiarize yourself with ICF language and with the definitions of the different components of physical therapy evaluation, the more effectively you will use these evaluation codes.

27. Documenting Examination: Definitions
A Review of Body Systems includes the following:
Musculoskeletal system: the assessment of gross symmetry, gross range of motion, gross strength, height, and weight
Neuromuscular system: a general assessment of gross coordinated movement (eg, balance, gait, locomotion, transfers, and transitions) and motor function (motor control and motor learning)
Cardiovascular/pulmonary system: the assessment of heart rate, respiratory rate, blood pressure, and edema
Integumentary system: the assessment of pliability (texture), presence of scar formation, skin color, and skin integrity
A review of body systems also includes cognitive assessment of the patient’s ability to make needs known, level of consciousness and, orientation (person, place, and time), expected emotional/behavioral responses, and learning preferences (eg, learning barriers, education needs)
©2017 American Physical Therapy Association. All rights reserved.
Let’s start with the definitions of “body systems,” and the language found in the introductory paragraphs to the evaluation codes.
The physical therapist examines these 4 body systems during the evaluation process. The terms should look familiar, as they have long been part of how physical therapist practice is described in professional documents and publications. Examples of each system are published  as guidance for the therapist in their evaluation and organization of their documentation.
When you are reviewing these body systems during an evaluation, more than one system could be involved in reason for the patient’s visit. Include in your documentation your review of all 4 systems, noting which appear to contribute to the patient’s condition and which do not.
A review of any of the body systems also includes the assessment of the patient’s ability to make their needs known, their level of consciousness and orientation (person, place, and time), expected emotional/behavioral responses, and learning preferences (eg, learning barriers, education needs). These overarching cognitive aspects should be considered and documented.

28. Documenting Examination: Definitions
Body Functions
Physiological functions of body systems
Blood pressure, heart rate, vestibular, sleep
Includes psychological functions
Body Structures
Anatomical parts of the body
Soft tissue, joint, bone, skin, spinal cord
©2017 American Physical Therapy Association. All rights reserved.
“Body functions” and “body structures” are ICF terms, but they also are reflected in the Guide to Physical Therapist Practice. For example, in the Introduction: 
“[Physical therapists’] services prevent, minimize, or eliminate impairments of body functions and structures, activity limitations, and participation restrictions. Physical therapy is provided for individuals of all ages who have or may develop impairments, activity limitations, and participation restrictions related to (1) conditions of the musculoskeletal, neuromuscular, cardiovascular, pulmonary, and/or integumentary systems or (2) the negative effects attributable to unique personal and environmental factors as they relate to human performance.”
Introduction to the Guide to Physical Therapist Practice. Guide to Physical Therapist Practice 3.0. Alexandria, VA: American Physical Therapy Association; Accessed December 8, 2016.

29. Documenting Examination: Definitions
Activity Limitations
Difficulties or restrictions experienced by an individual in the execution of a task or action
Self care: hygiene, dressing, etc
Mobility: changing or maintaining positions, walking, carrying, handling objects, etc
Other ADLs: household tasks, assisting others, etc
©2017 American Physical Therapy Association. All rights reserved.
“Activity limitations” is another ICF term included in the new coding language. This communicates the functional status of the patient at the time of the evaluation.
Some common examples are provided here. If you are familiar with the G-codes reported when documenting functional limitation restrictions, then you already are familiar with the various activity limitations that can be reported to support the level of complexity of your evaluation.

30. Documenting Examination: Definitions
Participation Restrictions
Difficulties or restrictions experienced by an individual in societal aspects of functioning or in life situations
Participating in domestic life
Participating as a student or employee
Participating as a member of a community
Accessing public transportation or other services
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“Participation restrictions” is the final ICF term included in the new coding language. Like “activity limitations,” it also communicates the functional status of the patient at the time of the evaluation, in terms of impact on the patient’s ability to be actively involved in life situations.

31. Documenting Examination: Using Determining Factors to Support Complexity
Condition
Body Structures/
Body Functions
Activity Limitations
Participation Restrictions
Number of Elements
Sprained wrist
Decreased mobility and pain in wrist and hand
Inability to grasp, pick up, or manipulate objects
None 3
Low back pain
Decreased mobility and pain L-S spine
Difficulty maintaining sitting or standing postures, and lifting over 5 lbs
Unable to perform 50% of work tasks 5
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This chart provides 2 examples of accounting for the elements of body functions and structures, activity limitations, and participation restrictions in determining evaluation complexity. Remember, the other components of selecting a level of complexity factor in as well, so, for example, the low back pain scenario in the chart meets the moderate complexity level—3 or more elements—only if the other components of history and clinical presentation also are at that level.

32. Documenting Examination: Describing Clinical Presentation
Patient interview (nature)
Observing patient response to exam (behavior)
Stable, uncomplicated, straightforward, problem-focused
Evolving, characteristics of patient’s condition are changing, complaints, and/or cognitive deficits
Unstable, characteristics of patient’s condition and are unpredictable, and/or significant cognitive deficits affecting safety
©2017 American Physical Therapy Association. All rights reserved.
Clinical presentation refers to the typical physical signs and symptoms that are associated with a particular disease process, injury, or condition. The PT’s interpretation of the clinical presentation contributes to the reporting of a therapy diagnosis.
For example, a medical diagnosis of fibromyalgia may include more than 3 months of the patient complaining of widespread body pain and tenderness. This could initially reflect a “stable” presentation to the PT who is treating the signs and symptoms of this medical condition, but upon interview, the patient could describe other aspects of their condition that are evolving and changing, or are unstable and unpredictable. These could include sleep patterns, and cognitive functions related to household tasks or decision making. It is the patient’s presentation—not only the involved system, structure, or function—that is impacted.
Another example is a patient with a hip fracture. The patient may stable, but the impact of immobility has caused some pain in the opposite hip and low back that varies with each day, or has caused constipation making ability to participate in rehab uncomfortable.

33. Documenting Examination: Clinical Judgment
History + physical exam + clinical presentation contribute to decisions reflecting clinical judgment
To achieve good outcomes, PTs use clinical judgment to determine the overall severity of patients’ complaint/condition and make appropriate decisions for interventions based on their patient assessment, at each encounter or session, supported as much as possible by current best evidence
©2017 American Physical Therapy Association. All rights reserved.
Your clinical judgment is key in determining the level of complexity with your patient.
Your clinical decision making is based on your ability to interview the patient and develop a full history of what’s pertinent in your exam. The exam addresses all areas that impact the patient’s ability to function.
The clinical presentation, in general, is how stable the patient is in their current condition.
Pull all of this together in your clinical decision making to determine the level of complexity.
Use your judgment throughout the process and throughout your patient-therapist relationship. Your clinical judgment is key along with the ability to effectively communicate what’s new and different.

34. Coding Physical Therapist Evaluations in 2017: Key Points
Evaluations reflect 3 levels of key elements: history, examination, clinical presentation, and review of standardized assessment tools. The PT applies clinical judgment to all of these to determine and report complexity level.
Communicating the assessment of key elements in a clear and objective manner is critical to avoid miscoding.
Reevaluations are performed when the clinician needs this level of information to make decisions on progressing, discharging, and or referring to other providers. Reevaluation is described by a single code, not tiered by complexity.
Physical performance tests and measures and other assessment codes (assistive technology, wheelchair) remain separately reportable and subject to payer policy.
©2017 American Physical Therapy Association. All rights reserved.
Before you move on to applying this knowledge to some clinical scenarios, here are some key points to remember when reporting the complexity of the PT evaluation, reporting a reevaluation, and performing separately reported physical performance tests and measures or other assessments.

35. Impact of Reflecting Complexity in Clinical Decision Making
Reflect complexity of patient in order to better determine the management path
Assessment tools at the front end and outcomes reported at the back end differentiate how patients are managed for potential development of reformed payment model
Address variation in care
©2017 American Physical Therapy Association. All rights reserved.
In addition, here are the positive impacts that using clinical decision making during evaluations to select a level of complexity can have:
You can better determine the management path for your patient if you establish the complexity of their presentation during evaluation.
By using assessment tools at the beginning of the plan of care, and outcome measures at the end, you can better quantify each patient’s progress toward goals and differentiate among patient outcomes, aligning with payment and health care reform models.
Assessment measures and outcome measures also enable PTs and the profession to address variations in care.

36. PAYMENT FOR PHYSICAL THERAPY EVALUATIONS
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37. CMS Fee Schedule Rule for 2017
All 3 evaluation codes will be reimbursed at the same level.
“...we proposed to adopt the new CPT codes for use in CY However, given our concerns about appropriate pricing and payment for the stratified services, we proposed to price the services described...as a group instead of individually.”(Federal register (FR) , Final Rule MPFS p 601)
”We are finalizing our proposal to a) accept the new CPT codes and...value the PT and OT complexity level evaluations as groups of services rather than individually by assigning a work RVU of 1.2 to each complexity level...and are finalizing a work RVU of 0.75 for each (re-evaluation) code. (FR, Final Rule MPFS, p.617)
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In July 2016, CMS released the proposed pule indicating that all 3 evaluation codes would be reimbursed at the same level. This occurred even though the codes had been assigned stratified values in the AMA RUC (Relative-Value Update Committee) process.
CMS stated it was concerned it could not reasonably predict the use of the different code levels and that costs would go up, preventing it from maintaining budget neutrality. As is normally the case, the code values were not published in the proposed rule.
In their comments to the proposed rule, APTA and other stakeholders expressed disagreement and frustration with this decision. CMS was asked to reconsider and perhaps provide other options for payment of PT evaluations and reevaluations.
In the final rule, published November 2, CMS did not change its approach to keeping a single value for the evaluation codes, and the value of the new codes remained the same as the old code. However, the agency did address other concerns. For one, the rate for the reevaluation code was increased to the value recommended by the AMA RUC. And CMS delayed updating the Medicare benefit policy manual regulations, meaning that PTs will not be penalized in 2017 during review if they haven’t complied with new policies related to the new codes.
Keep in mind, though, that PTs still are liable for compliance to the existing Medicare manual regulations.
It remains unclear as to how other payers will handle payment for these new evaluation codes. Will they follow Medicare policy or decide to value the codes differently as suggested by AMA? Typically, third-party payers review RVUs as published in the Federal Register, assess Medicare’s approach to payment, and then decide how to proceed themselves. This could mean following Medicare, applying their own formulas to determine rates, or taking other approaches.
One of the most important things to note as you become familiar with documenting 3 levels of evaluation complexity is this: CMS plans to collect and assess data on the use of these codes over the next year to determine target spending and potential changes to code values in subsequent fee schedule updates.
It is, therefore, critical for providers to learn and code correctly, despite the current lack of a payment differential.

38. CMS Fee Schedule Rule for 2017 (continued)
“We understand the many requests for delay of new documentation requirements during the initial year of their use. As such, for CY 2017 we will delay changes to our current manual instructions...(FR, Final Rule MPFS 2017, page 614)
“CMS defines the codes for these evaluations as ‘always therapy’. ...they always represent therapy services regardless of who performs them and always require a therapy modifier, GP or GO to signify that the services are furnished under a PT or OT plan of care...”(FR Final Rule MPFS 2017, Page 617)
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39. 2017 Medicare Payment for Evaluation & Reevaluation Codes
Summary of MPFS Final Rule:
Work values remain the same for all levels of PT and OT evaluations (1.20 Work RVU)
PT and OT reevaluation work values will be 0.75, an increase from 0.60
CMS will delay changes to the Medicare Benefit Policy Manual (MBPM), Ch 15, Section regarding new PT/OT evaluation and reevaluation codes
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The work RVU (which has the largest impact on the pricing of the evaluation service) will remain the same for all 3 evaluation codes through This is the same work RVU (1.20) that has applied to physical therapy evaluation since 1998.
The PT and OT reevaluations will have a work value of 0.75, which was recommended by the AMA RUC through the survey process. CMS explained in the final MPFS its rationale for increasing the value as recognition of “changes in physical therapists’ practice” since 1997, when the values were initially established.
CMS and its Medicare administrative contractors (MACs) will continue to use the current guidance regarding the reporting and documentation of evaluations as referenced in the Medicare Benefit Policy Manual. PT and OT services, including evaluation and documentation requirements and guidelines, are referred to in chapter 15, sections

40. RESOURCES
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41. Physical Therapy Evaluation & Reevaluation Codes: Resources
APTA Website Resources
APTA Guide to Physical Therapist Practice
Gordon J, Quinn L. Functional Outcomes Documentation for Rehabilitation. 3rd ed. Saunders;
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42. Physical Therapy Evaluation & Reevaluation Codes: Resources
Federal Register 2017 Medicare Program
International Classification of Functioning, Disability and Health, Geneva,
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43. Clinical scenarios and suggested coding
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Following are examples of clinical scenarios for which the evaluation codes are applied.
The first few slides depict examples of a clinical scenario describing each level of complexity for the same or similar primary condition (R ankle sprain). This takes you through how this patient presents as their evaluation reflects a low, moderate, and high complexity level.
Then there are 3 examples of clinical scenarios of 3 different patients, each reflecting a different complexity level for their evaluation.
To proceed, read through the scenario, take notes, and use the information found on slides 32, 33, and 34 to code the complexity level of the evaluation described. After doing so, review the slide that reveals the coding recommendation and the support found in the scenario for that decision.

44. Sample Patient #1: Neurology
A 65-year-old male was referred to physical therapy. s/p CVA for gait and balance exercises. He received 10 days of inpatient rehabilitation and was discharged home with his wife 2 days ago. He presents with mild left hemiparesis due to a right-sided lesion. The patient reported that it is getting easier for him to walk up and down the 12 steps to get to the upper level of the house using the right handrail and a step-to gait pattern with just a little help from his wife. The patient is able to ambulate with a straight cane on level surfaces in the house modified independently, but requires close supervision for community ambulation (about 1,000 feet) and minimal assistance on un level surfaces such as curbs. PMH/PSH is significant for HTN and atrial fibrillation. Recent test results by his cardiologist indicate that his medication to control the effects of AF will have to be modified. The cardiologist will be contacted to discuss the outcome.
Examination:
Modified Ashworth scale left upper and lower extremities = 0.
Coordination tests: 5-second finger-to-nose: R: 5 times; L 3 times; 5 second heel-to-shin: R 5 times; L 3 times.
Gait speed = 0.8 m/s. Berg Balance Scale = 46/56.
Dynamic Gait Index = 18/24.
Physical therapy goals include improved safety and mobility within the community. Independence with ambulating on even/uneven surfaces and stairs. Independence with performing a home exercise program for strength and coordination of left UE and LE. Improved overall functional balance and ambulation. Plan of care includes neuromuscular reeducation, gait training, functional training, and therapeutic activities to return the patient to his premorbid level of activity.
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45. Sample Patient #1 Answer: 97162 Moderate-complexity evaluation
A 65-year-old male was referred to physical therapy. s/p CVA for gait and balance exercises. He received 10 days of inpatient rehabilitation and was discharged home with his wife 2 days ago. He presents with mild left hemiparesis due to a right-sided lesion. The patient is able to ambulate with a straight cane on level surfaces in the house modified independently, but requires close supervision for community ambulation (about 1,000 feet) and minimal assistance on un level surfaces such as curbs. PMH/PSH is significant for HTN and atrial fibrillation. Recent test results by his cardiologist indicate that his medication to control the effects of AF will have to be modified. The cardiologist will be contacted to discuss the outcome.
Examination:
modified Ashworth scale left upper and lower extremities = 0
Gait speed = 0.8 m/s. Berg Balance Scale = 46/56
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History
Examination
Presentation
Decision-Making
Environmental limitations
HTN and a-fib
Strength
Coordination
Decreased balance
Decreased walking speed
Decreased walking abilities
Evolving AF presentation
Decreased community ambulation
Decreased speed/coordination Left UE/LE
Moderate complexity

46. Sample Patient #2: Musculoskeletal
32-year-old male computer programmer presents to the clinic non weight bearing (NWB) on his right lower extremity using crutches. PMHx is significant for ETOH abuse, NIDDM, BMI = 30. He reports that 6 months ago he fractured his patella playing softball and underwent open reduction internal fixation of his right patella. After surgery, he spent 6 weeks in a long-leg knee immobilizer, NWB. Since the surgery, he has been “suffering” from moderate right knee pain and has not returned to walking without an ambulatory device or driving. The radiographic reports indicate that there is mal-union noted in the distal patella. He reports that he has not returned to the surgeon for follow up. He reports that the medication is the only thing that helps his pain as he has been consistently taking Vicodin daily since the surgery. He delayed beginning physical therapy until now as “he did not feel ready.”
Examination:
Right knee ROM degrees. He is able to tolerate 30 lbs of weight in static standing on RLE but reports moderate discomfort.
Pain scale is 5-6/10. LEFS = 35%. FABQW = 35.
Manual muscle tests of the quadriceps and hamstrings were undetermined due to severe pain.
Knee (tibial-femoral and patello-femoral) joint accessory motions were restricted.
Physical therapy goals were to normalize knee range of motion and strength, and return the patient back to work and normal activities of daily living. Plan of care includes therapeutic exercises, manual therapy, gait training and functional activity training. The PT will coordinate the plan of care with the orthopedic surgeon prior to next visit.
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47. Sample Patient #2 Answer: 97163 High-complexity evaluation
32-year-old male computer programmer presents to the clinic non weight bearing (NWB) on his right lower extremity using crutches. PMHx is significant for ETOH abuse, NIDDM, BMI = 30. He reports that 6 months ago he fractured his patella playing softball and underwent open reduction internal fixation of his right patella. After surgery, he spent 6 weeks in a long-leg knee immobilizer, NWB. Since the surgery, he has been “suffering” from moderate right knee pain and has not returned to walking without an ambulatory device or driving. He delayed beginning physical therapy until now as “he did not feel ready.”
Examination:
right knee ROM degrees. He is able to tolerate 30 lbs. of weight in static standing on RLE but reports moderate discomfort
Pain scale is 5-6/10. LEFS = 35%. FABQW = 35
Knee (Tibial-femoral and Patello-femoral) joint accessory motions were restricted.
©2017 American Physical Therapy Association. All rights reserved.
History
Examination
Presentation
Decision-Making
NIDDM
BMI = 30
Psycho social factors: substance dependence
Chronic pain
LEFS, ROM, muscle strenghth
FABQ
Restricted accessory motion
Gait abnormality
Prolonged NWB
Stability of fracture unstable
FABQW score indicates unpredictability as it relates to return to work function.
High complexity

48. Sample Patient #3: Pediatric
5-year-old girl presents to the clinic one month s/p percutaneous left heel cord release to facilitate ambulation with heel strike at initial contact rather than walking on her toe on the left. Past medical history is significant for left hemiplegia cerebral palsy. Level 1 - Gross Motor Function Classification System (GMFCS). Prior to surgery, she had zero degrees of passive dorsiflexion. Her mother reported that she was having increasing difficulty in ambulation.
Examination:
Full passive dorsiflexion on the left but complains of pain with passive stretch to her gastroc-soleus muscle.
Stands independently but does not bear weight on her left foot and maintains the ankle in plantarflexion. Her mother reports that she presently crawls rather than walks around the home
AROM of Left ankle: dorsiflexion 6, plantarflexion 40. The goal of therapy is for independent ambulation without assistive device.
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49. Sample Patient #3 Answer: 97161 Low-complexity evaluation
5-year-old girl presents to the clinic one month s/p percutaneous left heel cord release to facilitate ambulation with heel strike at initial contact rather than walking on her toe on the left. Past medical history is significant for left hemiplegia cerebral palsy. Level 1 - Gross Motor Function Classification System (GMFCS). Prior to surgery, she had zero degrees of passive dorsiflexion. Her mother reported that she was having increasing difficulty in ambulation.
Examination:
Full passive dorsiflexion on the left but complains of pain with passive stretch to her gastroc-soleus muscle.
Stands independently but does not bear weight on her left foot and maintains the ankle in plantarflexion. Her mother reports that she presently crawls rather than walks around the home.
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History
Examination
Presentation
Decision-Making
L hemiplegic CP
GMFCS I
PROM L ankle
Pain
Decreased weight bearing L abnormal/reduced mobility
Stable, uncomplicated, improving
Low complexity

50. Sample Patient #4: Geriatrics
A 70-year-old male office worker presents to physical therapy with low back pain with a VAS pain = 8/10 after working on his garden and taking a long car ride to pick up his granddaughter from college. He also is now experiencing pain in his right posterior leg and lateral foot. Upon evaluation the physical therapist’s clinical impression is that the patient’s activities of gardening and driving have led to the onset of a new episode of back pain with potential new radicular involvement. PMHx is significant for a recent exacerbation of gout BLE.
Examination:
Impairments were noted in trunk ROM and muscle strength of the lower quarter
Neurologic status: myotomes unremarkable. However, sensation to light touch is diminished over the right lateral leg and foot.
Trunk flexion is markedly limited and is painful. In addition, a lateral shift of the lumbar spine to the left is noted. Trunk extension is limited but repeated trunk extension centralizes his pain
Oswestry Low Back Pain Disability Questionnaire = 42%
The therapist communicates these findings to the patient’s physician and recommends a plan of care for additional physical therapy to manage the symptoms including manual therapy and extension exercises to centralize his complaints of pain.
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51. Sample Patient #4 Answer: 97162 Moderate-complexity evaluation
A 70-year-old male office worker presents to physical therapy with low back pain with a VAS pain = 8/10 after working on his garden and taking a long car ride to pick up his granddaughter from college. He also is now experiencing pain in his right posterior leg and lateral foot. PMHx is significant for a recent exacerbation of gout BLE.
Examination:
Impairments were noted in trunk ROM
muscle strength of the lower quarter
Neurologic status: myotomes unremarkable. However, sensation to light touch is diminished over the right lateral leg and foot.
Trunk flexion is markedly limited and is painful
History
Examination
Presentation
Decision-Making
Exacerbation of gout
Impairments trunk ROM
Decreased muscle strength of the lower quarter
Sensation to light touch is diminished over the right lateral leg and foot.
Oswestry = 42%
Evolving
Peripheral symptoms RLE
Consider compensatory movement that maybe caused by exacerbation of gout
Moderate complexity
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