Document Evaluation Complexity
Effective January 2017, the single CPT codes for physical and occupational therapy evaluation are each being replaced by three complexity-based evaluation codes.
The information in this topic helps you decide whether an evaluation is low, moderate, or high complexity. You should select the least-complex code described by all of the applicable factors.
Warning: Do not use the legacy evaluation codes for any dates of service after January 1, 2017 unless the legacy codes are specifically required by the payer. All payers that are required to use HIPAA compliant data sets, which includes Medicare and most commercial payers, require the new codes. The legacy codes will still be required for a limited set of worker’s comp and auto insurers.
Physical therapy evaluation codes
PT evaluation CPT code table
Clinical documentation must support ratings in each category. Columns are defined in the next section.
| CPT code and description | Personal factors | Physical factors | Stability | Clinical decisions |
|---|---|---|---|---|
| 97161 – Low-Complexity Eval | None | 1 or 2 body structures affected or activity limitations | Stable | Not complicated |
| 97162 – Moderate-Complexity Eval | 1 or 2 | 3 body structures affected or activities limited | Evolving | Moderately complicated |
| 97163 – High-Complexity Eval | 3 or more | 4 or more body structures affected or activity limitations | Unstable | Unpredictable clinical presentation |
| 97164 – Re-evaluation | Not applicable | Not applicable | Not applicable | Not applicable |
PT evaluation CPT code column definitions
Clinical documentation must support ratings in each category.
CPT code
Numerical CPT code and description.
Personal factors
Personal factors such as sex, age, coping styles, social background, education, and overall behavior patterns that might influence how a disability is experienced by an individual.
Also includes comorbidities that impact current function and the ability to progress through a Plan of Care.
Physical factors
- Body functions – Physiological and psychological functions of body systems
- Activity limitations – Limitations on an individual's ability to execute a task or action
- Participation restrictions – Problems an individual might experience when involved in life situations
Stability
Frequent acute episodes, fluctuation in pain, reported outcomes, and functional tests, as well as variable response to activity or prior treatment.
Clinical decisions
Complexity of clinical decision-making. Therapists should consider clinical patterns assessed in initial evaluation classifications, patient response to examination, and aggravating and easing signs.
Occupational therapy evaluation codes
OT evaluation CPT code table
Clinical documentation must support ratings in each category. Columns are defined in the next section.
| CPT code | Performance deficits | Clinical decisions | Comorbidities affecting performance | Assistance to complete eval |
|---|---|---|---|---|
| 97165 – Low-Complexity Evaluation | 1–3 | Low complexity | None | None |
| 97166 – Moderate-Complexity Evaluation |
3–5 |
Moderate complexity | Maybe | Minimal to moderate |
| 97167 – High-Complexity Evaluation | 5 or more | High complexity | Yes | Extensive |
| 97168 – Re-evaluation | Not applicable | Not applicable | Not applicable | Not applicable |
OT evaluation CPT code column definitions
Clinical documentation must support ratings in each category.
Performance deficits
Deficits relating to physical, cognitive, or psychosocial skills that result in activity limitations or participation restrictions.
Clinical decisions
Complexity of clinical decision-making based on analysis of the occupational profile, analysis of data from problem-focused assessments, and consideration of treatment options.
Comorbidities affecting performance
How much comorbidities are affecting occupational performance.
Assistance to complete eval
Level of assistance that the patient required to complete the evaluation. For example, the patient might require physical or verbal cuing.
Manage evaluation codes in templates
Update evaluation templates
Clinicient has added evaluation complexity topics to the topic library in the Topic Editor. It lists complexity factors for reference. There are sections in which you can document patient health history, affected systems, and other factors that determine evaluation complexity.
The instructions below explain how to add the evaluation complexity topic into an evaluation template. For general information about using and updating templates and topics, refer to Chart Topics and Templates and Clinical Content Setup.
- Add evaluation complexity topic content to appropriate topics:
- In the Templates menu, click Topics.
Or
On the Chart F4 tab, click
. - In the Topic Editor, select the evaluation complexity topic content that you need. Both topics are located under Evaluation Complexity.
- In the Topics for Selected Item section, select topics that should include that content.
- Click
.
- In the Templates menu, click Topics.
- Add the complexity topic to evaluation templates:
- In the Templates menu, click Chart Templates.
Or
On the Chart F4 tab, click
and then click Edit Chart Templates. - Click the evaluation template that you want to update.
- Select the evaluation complexity topic that contains the content that you want to add to the selected template.
- Click
.
- In the Templates menu, click Chart Templates.
- Remove any old evaluation procedures and codes from templates by clearing the check box next to old evaluation documentation topics.
Use complexity-based evaluation codes in documentation
After you complete the patient evaluation, you should add documentation that supports the appropriate evaluation complexity.
- In the topic tree, click Procedures > Evaluation > Eval.
- Select the appropriate complexity-based evaluation code. In the example below, the therapist select ed PT Evaluation, Low Complexity.
