What You Need to Know About PQRS, Eval Codes, and the Therapy Cap in 2017

Out with the old – that is codes 97001-97004 – and in with the new.

New therapy evaluation and re-evaluation codes became effective January 1, 2017. But, as always there has been a good amount of confusion around how and when to use these codes, especially because they’re based off of the complexity of treatment in 2017.

What does complexity-based mean?
The updates to the current CPT coding structure now take into account the amount of time and complexity involved in the evaluation. See below the listings of the new eval codes for PT and OT. And, if you’re not sure which one to pick, check out this decision matrix.

Physical Therapy
97161 – Low Complexity
97162 – Moderate Complexity
97163 – High Complexity
97164 – PT Re-evaluation

Occupational Therapy
97165 – Low Complexity
97166 – Moderate Complexity
97167 – High Complexity
97168 – OT Re-evaluation

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Now, what about PQRS? Do we still report?
PQRS as it was experienced since its inception (in 2006 as PQRI) ended on December 31, 2016. PQRS reporting in 2016 will determine possible payment reduction for 2018. Moving forward in 2017, reporting of quality measures is now part of the MIPS program (Merit Based Incentive Program) established in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MIPS is one of two payment programs established in MACRA as part of the CMS Quality Payment Program (QPP).

PT, OT, and SLP are not currently identified as provider types that can participate in MIPS reporting at this time, but will become eligible in 2019. CMS has posted the measures for 2017, and for PT and OT the measure specifications generally remain the same. The 2017 measure specifications contain the applicable CPT codes for reporting in addition to all of the other requirements for successful reporting.

While it remains questionable if voluntary reporting by PT, OT, & SLP in 2017 will provide any “participation points” in the 2017 program (which determines bonus/deductions for 2019), therapists are encouraged to continue to report. Stay tuned for further updates and advice as CMS provides the therapy community with updates on voluntary participation. At this time only those in private practice (Medicare “supplier”) have been able to report. Rehab agencies, CORFs, SNF Part B and hospital outpatient have not been able to participate in measures reporting due to their status as a Medicare institutional facility (“provider”).

2017 Therapy Caps
The therapy cap for PT and SLP (combined) is $1980, and for OT it is also $1980. For all beneficiaries, including continuing patients, a new therapy cap is established for 2017. Billing for dates of service on or after 1/1/2017 begins anew, and the therapy cap exceptions process is only applicable for medically necessary therapy at/over $1980. The therapy cap exceptions process is in place through December 31, 2017. See CMS MedLearn Matters MM9448.

Don’t miss an upcoming webinar on January 31st with myself and Jerry Henderson to get all of the updates you need on recent Medicare changes. Reserve your spot today!