The NEW PT and OT Evaluation CPT Codes and Complexity Levels

If you haven’t heard about the new CPT codes for evaluations, then you must be living under a rock. That’s because January 1 marked the beginning of a number of new changes put in place by the CMS. Among them are some significant updates to the fee schedule.


Click here to read about the new evaluation codes for PTs and OTs in 2017.


We’ve already spoken at length about the new evaluation for PTs (CPT codes 97161, 97162, and 97163), and the new evaluation code for OTs (CPT codes 97165, 97166, and 97167). But, one thing we haven’t spoken about are the different complexity levels.


Each of the three evaluation CPT codes refers to a different level of complexity: ‘Low complexity’, ‘Moderate complexity’, and ‘High complexity’. But before we discuss situations where you’d use these codes, let’s take a step back and examine how the CMS defines complexity.


Low complexity evaluations take place when the patient is stable and exhibits uncomplicated characteristics.


For example, a patient may have suffered a grade 1 ankle sprain and is experiencing some pain and swelling. However, the symptoms can be predicted and the therapist can anticipate a full recovery—this constitutes a low complexity evaluation.


Moderate complexity evaluations are warranted when the patient’s condition has changing characteristics and an evolving clinical presentation.


Rick Gawenda of Gawenda Seminars and Consulting has provided us with an example: “A patient who had surgery to repair a fracture. [It’s been 8 weeks since the surgery] and the fracture isn’t healing as expected (i.e. delayed healing).” This can be considered a moderate complexity evaluation.


High complexity evaluations happen when the patient is unstable and has unpredictable characteristics.


For example, the patient may be an adolescent with cerebral palsy that’s prone to mood swings, has a low IQ, and extreme difficulty maintaining attention. If you were to perform an evaluation on this patient, it would be considered a high complexity evaluation.


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