How complex are PT cases in the workers’ comp industry? MedRisk looks for insight in new CPT code usage trends.

Two familiar CPT codes for PT evaluation and re-evaluation were eliminated in January 2017 and replaced by new codes that indicate complexity. 97001 was replaced by the following codes: 97161 (low complexity), 97162 (moderate) or 97163 (high complexity). 97002 was replaced by 97164.

While the Centers for Medicare & Medicaid Services (CMS) adopted the new codes, they are not yet using the tiered payment values recommended by the American Medical Association (AMA) RVS Update Committee (RUC).

CMS plans to monitor utilization trends this year prior to making any future changes on payment policy.

In this Industry Trends Update, MedRisk takes a look at early usage patterns cropping up in the workers’ compensation community.

As expected, usage of the new codes is trending upwards as state-by-state adoption unfolds and physical therapists become more familiar with how and when to use the codes (figure 1).

When the codes became effective in January 2017, the American Physical Therapy Association (APTA) estimated that CPT 97162 (moderately complex evaluation) would be reported 50 percent of the time, representing a “typical evaluation.” The low and high complexity codes (97161 and 97163) were each projected to be reported 25 percent of the time.

MedRisk’s sneak peek shows something slightly different for workers’ comp cases. Of the new evaluation codes, 97161 (a low complexity case) is currently being billed most frequently when the new codes are used (figure 2).

The difference between the APTA predictions for all physical therapy and MedRisk’s early data could be attributed to the nature of workers’ compensation cases – or to the fact that physical therapists are still educating themselves on how and when to use the correct codes.

Only time will tell before CMS, APTA, MedRisk and others can determine actual usage trends.