Founder Letter: My Evaluation of the New PT and OT Eval Codes

Over the last several years, healthcare providers in general—and rehab therapists, specifically—have been hit with a seemingly constant barrage of regulatory requirements. And the vast majority of these initiatives—PQRS, functional limitation reporting, MPPR, ICD-10, and the like—have either:

1. Had a direct negative impact on our payments, or
2. Forced us to devote extra time to satisfying the criteria of the requirements—with zero compensation for that time.

So, it should come as no surprise that the rehab therapy community tends to resist change. After all, it’s tough to see the long-term value of these programs when all they do in the short term is cause us to be paid less—even when, in many cases, we must put in more work. And that brings me to the topic of this post—something I’m sure you’ve all heard about by now: the new CPT codes for PT and OT evaluations.

These new codes—which will replace 97001, 97002, 97003, and 97004—are set to go into effect on January 1, 2017. That’s under two months from now. And this isn’t just a simple switcheroo: with this update, therapists must determine—and code for—the level of complexity associated with each patient evaluation (as discussed here, there are three possible levels of complexity: low, moderate, and high). And as with any other type of code selection, it’s on the provider to ensure his or her documentation adequately supports each coding choice.

The catch, of course, is that despite having to put additional time and effort into coding and documenting initial evaluations, PTs and OTs will not receive any additional reimbursement—even in cases when they do, in fact, perform highly complex evals. And as explained here, that doesn’t exactly sit well with a lot of folks in the rehab therapy community.

While I absolutely understand their frustrations—especially considering our industry’s long history of ever-increasing regulatory burden—I also know there’s more to the story. And while I might not wholeheartedly agree with the implementation of this complexity-based system in its current form—as it doesn’t truly close the loop on the value we, as therapists, provide to our patients—I do think the data it’ll generate could help move things in the right direction as far as payment goes.

I also understand CMS’s reluctance to implement differential values based on evaluative complexity as originally proposed (and as recommended by the APTA). After all, like any payer, CMS bases its payment rates on data—and because these codes are brand new, there’s no historical data available to inform those valuations. Then there’s the whole upcoding issue—that is, the concern that therapists, either intentionally or unintentionally, would code for a higher level of complexity than what’s actually appropriate in any given situation.

On the other side of the coin, therapists may worry that their documentation doesn’t support a higher level of complexity, even when it actually is appropriate to the situation—which could lead them to downcode in an effort to avoid scrutiny. Remember, knowledge is power—and the better we know the defining characteristics of each level of complexity, the more accurate our data will be. And that, in turn, enables us to paint a truer, clearer picture of the types of patients we’re seeing and treating.

Essentially, at this point, there are simply too many unknowns for CMS to jump head-first into a complexity-based payment system for therapy evaluations. But, allowing time for therapists to get comfortable with the new codes—without all of the reimbursement pressure—might not be a bad thing. In fact, it could actually benefit therapists in the long run, as it’ll:

1. allow us to really focus on understanding the different levels of complexity (and how to code for them), and
2. give CMS the time and data necessary to develop a fairer, more accurate payment structure.

And that, hopefully, will carry over into the new intervention coding system. (FYI: CMS and the AMA have decided to press pause on the implementation of a complexity-based coding system for therapy interventions, as they recognized the need for additional discussion and review.)

But, the quality of the data CMS collects with respect to evaluative complexity hinges on therapists’ willingness to put forth a good-faith effort to code accurately. No, you won’t receive higher reimbursements for that effort—which means you may be tempted to simply code each evaluation the same, regardless of its complexity. If we all approach this change with such an apathetic attitude, though, we’ll end up in pretty much the same boat we’re in now—because bad data isn’t much better than no data.

So, let’s show the healthcare powers that be—CMS included—that we, as an industry, are capable of producing strong, accurate data. Let’s start building the reputation we deserve as valuable members of our patients’ care teams—in terms of both the care we provide and the data we collect. Let’s prove that we can hang—no matter what regulatory curveballs come our way. After all, as history has taught us, we don’t always have control over the changes that affect us. But in this case, we do have control over the data we provide—and that data will inform the changes that affect us in the future.

Want to learn more about the new evaluative codes that go into effect on January 1, 2017? On December 15, 2016, I’ll team up with compliance guru Rick Gawenda to host a free webinar that’ll cover everything you need to know about these CPT coding updates. Learn more and register here.