Billing and Coding: Therapy Evaluation Coding Noridian Healthcare Solutions,
LLC is posting this article to assist providers in determining appropriate
coding for therapy evaluation services.  
  
Providers occasionally receive multiple physician orders for multiple
conditions for the same patient. Because of the multiple conditions and
specialization of therapists, this often results in the patient being
evaluated by multiple therapists of the same discipline. The Centers for
Medicare and Medicaid Services (CMS) does not require therapists to complete
separate evaluations and plans of care for the treatment of patients with
multiple medical conditions. The licensed clinician is expected to complete a
thorough initial patient evaluation, which would include an assessment for
each of the medical conditions requiring therapy treatment. Multiple
evaluations occurring during a single episode of care (within a single therapy
discipline) are not separately reimbursable except in the rare circumstance
described below. However, CMS does not restrict the number of therapists
(within a single therapy discipline) that can treat a patient. Providers may
choose to have one or more on-staff therapists that specialize in the
treatment of specific medical conditions (specialty therapists) work with the
patient to optimize their full rehabilitation potential.  
  
 _Coding Considerations_  
  
A patient is being treated at the outpatient therapy clinic for condition A.
During the course of treatment for condition A, the patient comes to the
clinic for treatment of a new diagnosis, condition B:  
  
_Scenario 1:_ When condition B _is related_ to condition A, then the
appropriate code to bill for the evaluation service provided is a re-
evaluation using CPT code 97164 - Re-evaluation of physical therapy
established plan of care. Typically, _20 minutes_ are spent face-to-face with
the patient and/or family or 97168 - Reevaluation of occupational therapy
established plan of care. Typically, _30 minutes_ are spent face-to-face with
the patient and/or family for Occupational Therapists.  
  
Example: A patient is receiving treatment for a total knee arthroplasty (TKA).
During the episode of care, the patient develops shoulder pain. The clinician
determines the pain is due to use of a walker, which the patient is using as a
result of the TKA. In this scenario, the shoulder pain is a condition related
to the TKA. Therefore, it is appropriate for the clinician to provide a re-
evaluation of the patient due to this related condition.  
  
 _Scenario 2:_ When condition B _is not related_ , directly or indirectly, to
condition A, then the evaluation of condition B would warrant billing for a
new evaluation using CPT codes 97161 - Physical therapy evaluation: low
complexity. Typically, _20 minutes_ are spent face-to-face with the patient
and/or family, 97162 - Physical therapy evaluation: moderate complexity.
Typically, _30 minutes_ are spent face-to-face with the patient and/or family
or 97163 - Physical therapy evaluation: high complexity. Typically, _45
minutes_ are spent face-to-face with the patient and/or family for Physical
Therapy or 97165 - Occupational therapy evaluation, low complexity. Typically,
_30 minutes_ are spent face-to-face with the patient and/or family, 97166 -
Occupational therapy evaluation, moderate complexity. Typically, _45 minutes_
are spent face-to-face with the patient and/or family or 97167 - Occupational
therapy evaluation, high complexity. Typically, _60 minutes_ are spent face-
to-face with the patient and/or family for Occupational Therapists.  
  
Example: A patient is receiving treatment following a TKA. During the episode
of care for the TKA, the patient develops an acute rotator cuff injury from an
accident at home. The clinician determines the rotator cuff injury is not
related to the TKA. Therefore, it is appropriate for the clinician to provide
a new evaluation for the rotator cuff injury since it a newly identified
diagnosis for an unrelated condition.  
  
In either case, it is necessary for the documentation to accurately support
the services provided.  
 **  
Source:  
Medicare Benefit Policy Manual[(MBPM)](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/bp102c15.pdf) Chapter 15 section 220(A)
and 220.3.5(A)**