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Billing: PT and OT initial evaluation codes

History component for PT (Codes 97161, 97162, 97163) and OT (Codes 97165, 97166, 97167). The
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History component for PT (Codes 97161, 97162, 97163) and OT (Codes 97165, 97166, 97167)

The justification of coding levels for therapy evaluations is a combination of the history, the exam, the clinical presentation and the medical decision-making 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:

  • A prior injury, therapy or surgery in the same area
  • A history of pain in the same area lasting more than three months
  • The side effects of current medications

Two examples of contributory personal factors

  • Patient's medication X is causing drowsiness. Balance and vision are affected during exercises.
  • The patient is a sedentary 62-year-old with no motivation to do exercises at home or during PT sessions.

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:

  • Diabetes, circulatory problems, heart disease or asthma
  • Chronic history of pain from arthritis, fibromyalgia, etc.
  • Smoking history and current use
  • Hearing or vision loss
  • Obesity with a body mass index of 30 or higher

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

  • A 66-year-old female with a six-month history of pain and stiffness in her right shoulder. Using NSAIDs and self-limiting her activities. History of poorly controlled diabetes. (Two factors: Chronicity of present condition and diabetes status)
  • The 35-year-old male appears on crutches and is non-weight bearing (NWB) on his right lower extremity. Past medical history significant for diabetes and alcohol abuse, BMI = 36. He reports he fractured his right patella in a car accident and underwent open reduction internal fixation five months ago. He spent six weeks in a normal weight-bearing long leg knee immobilizer. Since surgery, he has been suffering from moderate right knee pain and has not been able to walk without assistance. (Four factors: Diabetes, alcohol abuse, BMI over 30 and pain lasting more than three months following surgery)

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.

If you have questions or want to learn more about opportunities to improve billing practices in your office, please contact Pinnacol's billing auditors at billingsuccess@pinnacol.com.

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