Stay compliant with new CPT Codes!

By Mia Thomas, PT, DPT



Another year and another bunch of changes with coding and billing. Medicare caps continue to increase, to $1,980; Physician Quality Reporting System (more commonly known to practitioners as PQRS) is no longer required; and the biggest change of all, new evaluation and re-evaluation coding is upon us.


Medicare caps did increase this year, but please note that physical therapy and sleep language pathology services are still combined, while occupational therapy services continue to have their separate $1,980 cap. Centers for Medicare & Medicaid Services (CMS) also changed their policy for manual medical reviewing of any claims that exceed $3,700; now, only claims that meet specific criteria will undergo a manual medical review.


While PQRS is no longer required, functional limitation reporting is still mandatory for all evaluations and re-evaluations; if functional limitations are not reported, claims will be automatically denied. Do not celebrate the loss of PQRS too quickly, because it will be leaving something behind. A merit based incentive program is going to slowly replace PQRS; if you enjoyed the aspects of PQRS and would like to participate, it may be something your clinic can do voluntarily. However, you may not be eligible to participate in the actual program until 2019.


Finally, new evaluation and re-evaluation codes are here for all physical and occupatiaonal therapists!  The question is, who is using it and why are we doing it? New CPT codes will apply to all insurance companies covered under HIPPA, not just Medicare! The only insurance companies that are not mandated to use these new codes are workman’s compensation and no fault, as they do not work under HIPPA because they are not insurance companies.


Currently all of the evaluation codes reimburse the same, so why the switch? While the CPT for a low complexity evaluation versus a high complexity evaluation is the same right now, that is not the plan for the future. CMS is going to be using the first five months of the year to develop pricing structures that align with the value of the evaluation we are providing. This means they will be looking at the percentage of evaluations we bill as low complexity versus moderate or high complexity. CMS wanted to ensure coding was being performed accurately to create these prices, so please make sure you are following the guidelines for the different level evaluations!