January 4th, 2018
According to CGS Administrators, for initial evaluations, PTs shall use code 97161-97163 and OTs shall use code 97164-97167. Physicians and other qualified non-physician providers should use the evaluation and management codes 99201-99350 for evaluations.
Consider the following points when billing for an evaluation.
- These evaluation codes are untimed, billable as one unit.
- Do not bill for a therapy initial evaluation for each therapy discipline on more than one date of service. If an evaluation spans more than one day, the evaluation should only be billed as one unit for the entire evaluation service (typically billed on the day that the evaluation is completed). Do not count as therapy “treatment” the additional minutes needed to complete the evaluation during the subsequent session(s).
- Do not bill test and measurement, range of motion (ROM) or manual muscle testing (MMT) codes (CPT 95831-95834, 95851-95852, 97750, 97755) on the same day as the initial evaluation. The procedures performed are included in the initial evaluation codes and are not allowed by the Correct Coding Initiative (CCI) edits.
- Do not bill therapy screenings utilizing the evaluation codes. Screenings are not billable services.
- Evaluations for deconditioning after hospitalization where it is anticipated that prior functional abilities would spontaneously return through patient, caregiver and/or nursing activities are not considered medically necessary and are not covered.
- Pre-operative evaluations performed routinely to ascertain the patient’s post- surgical needs and/or to explain the services that will be provided post-operatively are non-covered. The patient’s post-op experience and functional limitations are unknown prior to the surgery and will at that time require a new evaluation of the situation when medically necessary.
- If treatment is given on the same day as the initial evaluation, the treatment is billed using the appropriate CPT codes. The documentation must clearly describe the treatment that was provided in addition to the evaluation.