The Centers for Medicare and Medicaid Introduce Final Rule for 2017

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


Earlier this month, the Center for Medicare and Medicaid (CMS) released their final rule for the 2017 calendar year. This new rule touches upon several important topics related to services paid under the Medicare Physician Fee Schedule, as well as a few important issues relevant to outpatient therapy services. In this article, we will be providing a brief rundown on some, but not all, of these changes.


New Therapy Cap


On January 1, 2017, the physical therapy and speech-language cap will be changed to $1,980.00. There’s also a separate $1,980 available to patients in need of occupational therapy treatment.


Therapy Cap Exceptions Process


The therapy cap exception use of the KX modifier remains in effect for all dates of service in 2017. Rick Gawenda of Gawenda Seminars and Consulting stated that “If a Medicare beneficiary exceeds the 2017 therapy cap threshold of $1,980 and the therapist determines therapy is still medically necessary and requires the unique skills of a therapist, the therapist would give the okay to use the KX modifier for services provided above the therapy cap dollar threshold.”


Manual Medical Review


In accordance with the passage of the CHIP Reauthorization Act of 2015, the CMS doesn’t need to review all claims that exceed the $3,700 threshold. However, they will be choosing the therapists and facilities that they review more carefully. They’ll be focusing on therapy providers with a higher claims denial rate in comparison to their peers.


New Evaluation Codes for PTs and OTs


There are a total of 6 new evaluation codes (CPT codes) for PTs and OTs. They are as follows:


  • 97161 – Physical therapy evaluation: low complexity
  • 97162 – Physical therapy evaluation: moderate complexity
  • 97163 – Physical therapy evaluation: high complexity
  • 97164 – Reevaluation of physical therapy established plan of care
  • 97165 – Occupational therapy evaluation, low complexity
  • 97166 – Occupational therapy evaluation, moderate complexity
  • 97167 – Occupational therapy evaluation, high complexity
  • 97168 – Reevaluation of occupational therapy established plan of care


Furthermore, Payment for re-evaluation CPT codes for PTs will be the same across the board.


When’s the best time to bill for a re-evaluation?  Click here to find out.


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