Making Sense of ‘Elements’ in the New Evaluation CPT Codes

Please note that this article contains information that is only relevant to American clinics.

 

After nearly two months of using the new evaluation CPT codes, there are still some questions that haven’t been answered. For instance, we’ve yet to discuss ‘elements’ and the role they play in physical therapy and occupational therapy evaluations. But before we get into the nitty gritty, let’s take a step back and define ‘elements’.

 

The Oxford Dictionary defines an element as a ‘rudiment of a subject’. When you look at that definition through the lens of PT evaluations, it’s plain to see that ‘elements’ are an essential component of this procedure.

 

The APTA classifiew ‘element’ to include body structures, functions, activity limitations, and/or participation restrictions. Then, use the elements identified in your evaluation to determine complexity level as the two are directly related.

 

Click here to access the APTA’s quick guide for the three levels of PT evaluations.

 

Complexity levels affect the number of elements that must be included in your evaluations. For example, a low complexity PT evaluation (CPT 97161) includes 1 to 2 elements. A moderate complexity PT evaluation (CPT 97162) includes 3 or more elements. And a high complexity PT evaluation (CPT 97163) includes 4 or more elements.

 

Example of Elements in a PT Evaluation

 

Thanks to the help of Rick Gawenda from Gawenda Seminars and Consulting, I’m going to provide you with a scenario in which you’d be performing an evaluation.

 

Let’s pretend that a 39-year-old gentleman named Tom was playing flag football when an opponent from the other team got a little too aggressive. He saw that Tom was going to throw a Hail Mary and he knocked the ball out of his hand with a swift but thunderous blow. This ended up tearing Tom’s rotator cuff, and he had to have it surgically repaired. It’s been six weeks since then and now he’s come to your clinic for an evaluation.

 

Tom claims that he’s having trouble sleeping because of the pain in his shoulder. It’s waking him up several times a night. He’s also experiencing difficulty raising his arm to do every day tasks like brush his teeth and put on his favorite hoodie. Tom is also unable to move large objects. Now let’s review some of the elements that were included in our subjective evaluation:

 

  • Tom claims to be experiencing pain. This counts as an element.
  • Tom has a limited range of motion in his shoulder, as proven by the fact that he can’t raise his arm to brush his teeth or put on his favorite hoodie. This counts as an element.
  • Tom isn’t able to lift heavy objects, and this points to limited muscle functions. This also counts as an element.
  • Tom can’t sleep through an entire night due to the discomfort caused by his injury, indicating an inability to maintain a lying position. This, too, counts as an element.

 

In sum, we were able to identify 4 unique elements during Tom’s evaluation. It can therefore be classified as a 97163 (i.e. a high complexity evaluation).

 

Please note that the above scenario is only an example. With a little bit of digging, you’d probably find that there are additional elements in play. Of course, these specific elements can be found in the International Classification of Functioning, Disability and Health (ICF) manual.

 

For more details on what qualifies as an element, click here to access an interactive ICF manual.

 

We hope you found this article helpful. To access more great content like this, head on over to the Gawenda Seminars and Consulting website and become a Gold Member today!