CPT Codes Heaven-Bound?

So long and farewell to PT and OT CPT codes 97001, 97002, 97003, and 97004!

According to The Department of Health and Human Services’ proposed rule, Physical and Occupational Therapy Evaluation codes will be changing effective on or after January 1, 2017.

The CPT Editorial Panel deleted the old PT and OT evaluation CPT codes and created eight new CPT codes. The new CPT codes contain descriptors of new coding requirements for each complexity level. The Physical and Occupational Therapist will need to learn the requirements for each complexity level. The complexity level will then identify the appropriate CPT evaluation code to use.

Each code describes the assessment process, drills down by personal factors and / or co-morbidities that impact the plan of care, identifies the number of body systems examined, the clinical presentation of the patient, the clinical decision making of the therapist (complexity level), and the number of face-to-face time minutes with the patient and / or family.

The table below provides a few* examples of code requirements.


97X63: PT Eval: High Complexity


1.     History of present problem with 3 or more personal factors and/or comorbidities

2.     Examines 4 or more elements from body structures and functions, activity limitations, and/or participation restrictions;

3.     The patient presents with unstable and unpredictable characteristics; and

4.     Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.

45 minutes

97X67 OT Eval:   High Complexity 1.     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;

2.     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

3.     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.

4.     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.

60 minutes

Therapists will need to be sure that standardized assessments are a part of their evaluative process. Please talk to your rehab provider to be sure they are aware of these changes and also discuss what their plans are for training therapists and managers. If you are a Functional Pathways’ partner, rest assured that the therapists and managers in your facility will be trained and ready to go!

Want more detailed information? Here is the link for the FY 2017 Proposed Rule.