New Physical Therapy Complexity Coding

New Physical Therapy Complexity Coding

William Meier, DPT University of North Florida

Objectives

Review the ICF model and its components Be able to integrate the ICF model into evaluations Explain the reasoning behind the development of the new codes Discuss the three new complexity codes and their components Discuss case studies and apply concepts to patient evaluations.

G-codes and Reevaluations

Outpatient vs. Inpatient Application of G-codes

3 special cases in acute care. Reevaluations for change in condition/Plan of Care

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ICF Model

ICF Model

Body functions: The physiological functions of body systems, including psychological functions.

Body structures: The structural or anatomical parts of the body ? regions.

Activity limitations: Difficulties an individual may have in executing a task, action, or activities.

Participation: Inability to participate as a part of society.

Environmental factors: facilitators or barriers.

Personal factors: Factors that influence how disability is experienced by the individual. Personal factors could exist but may or may not negatively impact the physical therapy plan of care.

Quick Reminders

Re-evaluation code is not described by complexity reported at the end of the POC or to update the POC

Time does not determine the CPT code you will pick

Code down based on the Patient Hx, Examination, Clinical Presentation, and Clinical decision-making

You are picking the code based off of the complexity of the evaluation!

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What are the new codes?

Mandated by CMS ? Center for Medicare and Medicaid Services accepted by commercial insurance.

Low, Mod, High complexity

Low ? 97161 Mod ? 97162 High ? 97163

Stratified payment system ? on the way

Importance of proper complexity.

Why do we care?

CPT data can be used to more clearly specify what was done

To assist with productivity measures Functional Outcome Measures!

Breaking Down the Codes

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Low Complexity- 97161

History

Examination

Presentation

A history with no personal factors and/or co- morbidities that impact the plan of care

An examination of body

A clinical presentation

system(s) using standardized with stable and/or

test and measures, patient uncomplicated

assessment instrument

characteristics

and/or measurable

assessment of functional

outcome addressing 1-2

elements from any of the

following: body structures

and functions, activity

limitations, and/or

participation restrictions

Decision-Making

Clinical decision making of low complexity

Moderate Complexity- 97162

History

Examination

Presentation

Decision-Making

A history with 1-2 personal factors and/or co-morbidities that impact the plan of care

An examination of body An evolving clinical

system(s) using

presentation with

standardized test and

changing

measures, patient

characteristics

assessment instrument

and/or measurable

assessment of functional

outcome addressing 3 or

more elements from any

of the following: body

structures and functions,

activity limitations, and/or

participation restrictions

Clinical decision making of moderate complexity

High Complexity- 97163

History

Examination

Presentation

Decision-Making

A history with 3 or more An examination of body An clinical presentation Clinical decision making

personal factors and/or system(s) using

with unstable and

of high complexity

co-morbidities that

standardized test and

unpredictable

impact the plan of care measures, patient

characteristics

assessment instrument

and/or measurable

assessment of functional

outcome addressing 4 or

more elements from any

of the following: body

structures and functions,

activity limitations, and/or

participation restrictions

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6/8/2017

Case Studies 5

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