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
6/8/2017 1
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!
6/8/2017 2
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
6/8/2017 3
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
6/8/2017 4
6/8/2017
Case Studies 5
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