CPT code 97163

CPT code 97163 is a high complexity code often used for physical therapy services. If you haven’t had a chance to read about the low and moderate complexity codes, follow the links to check them out.

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As we have discussed earlier, the tiered system of evaluation codes has been around since 2017. Gone are the days when only one code existed for initial evaluations. Since that time, practicing therapists have been comparing their patient case with a series of criteria that helps categorize patients in one of three groups – low, moderate or high complexity.

Despite initial whisperings amongst healthcare providers, this tiered system has not yet been linked to a tiered system of reimbursement, though this may in fact become a reality at some point. So while you may be questioning whether it really matters what code you choose, all of this information is being gathered and analyzed. The accuracy with which you select eval codes now may determine how you get paid for them in the future.

In the post on the low complexity evaluation code, 97161, we reviewed the components of a high quality new patient evaluation and introduced the criteria for each code.

In the second post on the moderate complexity code, 97162, we dove more deeply into the three components of the decision-making process and how to use them to select the correct code.

In this post we are going to review the high complexity CPT code 97163, spend some time discussing how to justify your decision within your documentation as well as other billing considerations.

CPT code 97163: High complexity evaluation

Before we dive into this code, let’s quickly review the purpose of CPT codes. CPT stands for current procedural terminology codes and is utilized to describe the physical therapy services rendered when submitting a claim to a third party payer. Some of the codes used commonly by physical therapists include 97110, therapeutic exercise, 97112, neuromuscular re-education and 97116, gait training. These codes provide healthcare providers a uniform language of coding for medical services and procedures.

The three complexity codes are derived from three different components of the exam, the patient history, the examination of body systems and the patient’s clinical presentation.

Code selection defaults to the column that houses the component with the lowest complexity no matter if one or two of the other components fall in higher columns. This means that an evaluation must meet all three criteria under the high complexity column to be billed as high complexity.

The chart below outlines the requirements for using each of the evaluation codes.

Support with documentation

While there is a good chance insurance will never look at many of your notes, thorough and accurate documentation is not only a legal and ethical requirement but also a part of good, collaborative care.

While these codes like CPT code 97163 are not yet tied to how much money the insurance company will pay for the evaluation, they are still likely using this information to determine if and how that change might occur in the future.

There are two approaches to providing supportive documentation to your selection of CPT code 97163.

This goes for the other two codes as well.

• First, you can list the relevant personal factors and/or comorbidities, body systems you included in your examination and clinical presentation throughout the examination and assessment. The information is there but someone reviewing your documentation may have to read through the entire thing to find the elements that support your decision.

• The second option is to include a quick statement at the bottom of your assessment that outlines your decision-making process. If your documentation system allows it, you may be able to create a smart phrase with drop down menus that you can quickly drop into the note. Depending on your clinic, you may choose to do this only in the case of moderate or high complexity evaluations. Here is an example of how that might look for a high complexity evaluation of a patient who comes to physical therapy for balance.

CPT code 97163 decision-making

• The patient has three or more personal factors and/or comorbidities relevant to the plan of care including: a progressive neurologic disease (Parkinson’s), a history of orthostatic hypotension and a history of anxiety around healthcare professionals.

• The evaluation required the examination of at least 4 body structures and functions, activity limitations, and/or participation restrictions in order to determine an appropriate plan of care including: fall risk, musculoskeletal impairments, aerobic tolerance and gait.

• This patient’s clinical presentation is determined to be UNSTABLE based on the fact that they have had frequent hospitalizations due to changes in status, unstable blood pressure and need for frequent medication adjustments.

Based on the history, examination of body systems and clinical presentation, the patient meets the criteria for a HIGH COMPLEXITY evaluation and CPT code 97163 is appropriate.

Other billing considerations

Now that you know which evaluation codes to choose, don’t forget other important billing considerations such as whether a KX modifier is needed for a patient that has exceeded the first tier of the Medicare CAP or if authorization needs to be requested for follow up visits.

Make sure you select relevant physical therapy ICD 10 codes and list any CPT codes or treatments you anticipate using throughout the patient’s care. Also, if you had the time to provide any treatment, don’t forget to bill for that time. Finally, if the patient has a Medicare or Medicare Advantage plan, don’t forget to send off that plan of care for signature.