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Therapy Evaluation Codes Expanded Under CMS' Proposed Rule [Ober|Kaler]

Payment Matters

The most significant change for physical and occupational therapists in the Medicare proposed Physician Fee Schedule for 2017 is the replacement of current CPT codes for evaluations and reevaluations. The change reflects the work of the APTA and AOTA to establish CPT evaluation and reevaluation codes for therapists that are more in line with physician evaluation and management codes, i.e., coding based on the complexity of the patient, the complexity of the therapist’s decision making, and the face-to-face time required to complete the assessment. CMS did not, however, agree to have different payment rates based on the differentiated codes at the current time, stating "concerns regarding appropriate valuation ... and potential upcoding." CMS recognizes extensive education would be key to ensuring therapists understand how to appropriately use these new codes.

The APTA announced it will lead the education efforts for physical therapists. For an overview of other proposed Medicare fee schedule changes affecting physical therapists, refer to APTA’s "Proposed Physician Fee Schedule: New Evaluation Codes, Same Payment" web post. In its "New Evaluation Codes for OT in Medicare Physician Fee Schedule Proposed Rule" web post, the AOTA is not only encouraging members to submit comments to the proposed rules, but is requesting its members to send feedback or concerns to For comments to CMS on the proposed rule, the deadline is September 6, 2016.


In addition to therapists taking advantage of APTA’s and AOTA’s advocacy and education on using the new codes, therapy companies will need to be sure that appropriate updates are made to their electronic health record documentation and billing software. In particular, changes should be designed to capture patient complexities and cue therapists to document all standardized assessment results in order to facilitate the correct code being reflected on the claim.

A version of this article appeared in the September 2016 issue of LARCM News, a publication of the Louisiana Association of Revenue Cycle Management. 

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