The justification of coding levels for therapy evaluations is a combination of the history, the exam, the clinical presentation and the medical decision-making (MDM) associated with the evaluation.
The history for initial therapy evaluations comprises two documentation components: personal factors and comorbidities. Notable conditions that exist prior to the current injury would be contributory if they influence the current function. The conditions will affect the plan of care and will affect the injured worker’s (IW’s) ability to progress through treatment.
Personal factors are problematic items that may influence how the IW experiences the injury or disability. Contributory factors are those such as an IW’s age, coping style, social background, living environment, education and behavior that negatively influence the plan of care. Examples of contributory personal factors include:
Two examples of contributory personal factors
Comorbidity is the presence of two or more chronic underlying diseases or conditions existing at the same time in an IW. Comorbidities that are considered contributory will necessitate modifications in the therapy treatment plan or delay the treatment response. The documentation must reflect why the comorbidity is contributory. Examples of possible comorbidities include:
Therapy evaluations are coded based on the complexity of the visit which ranges from low to high complexity. The documentation of history is one part of determining the correct coding level.
Only personal factors and comorbidities that complicate the plan of care should be counted. If no history components can be supported, you must report the lowest level of complexity, 97161 or 97165, regardless of the elements of the exam or the clinical decision making.
97161 / 97165 (low complexity) — the patient has a history of the present problem with no personal factors and/or comorbidities that impact the care plan
97162 / 97166 (moderate complexity) — one to two personal factors and/or comorbidities impact the care plan
97163 / 97167 (high complexity) — three or more personal factors and/or comorbidities impact the care plan
Two examples of contributory history
The coding level of initial therapy evaluations is a combination of the history, the exam, the presentation and the medical decision making. At least one or two personal factors or comorbidities must be documented to justify coding 97162 or 97166. Three or more personal factors or comorbidities are required to code 97163 or 97167.
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