Pt tiered eval

Determining Patient Complexity upon Physical Therapy Evaluation. Center for Medicare and Medicaid Services (CMS) tiered evaluation coding and billing. Demonstrating medical necessity.

1. Determining Patient Complexity: A Physical Therapy Perspective By Nico Olson-Studler, SPT, CPT

2. Objectives Understanding complexity levels Why tiered model The tiered evaluation model allows us to demonstrate our value as PTs!

3. The Eval

4. Updated CPT codes ( 97161) Low Complexity Evaluation (97162) Moderate Complexity Evaluation (97163) High Complexity Evaluation (97164) Re‐evaluation

5. Documenting Medical Necessity

6. Reformed payment model

7. Show me the evidence! Low: 46% Mod: 45% High: 9%

8. M25: joint disorders M54: dorsalgia (back/spine pain) M79: soft tissue disorders R26: gait and mobility abnormalities

9. New CPT codes Components: History Examination Presentation Clinical decision making

10. Complexity rubric Complexity Level:   Low Complexity Moderate Complexity High Complexity History:   1-2 3 + Exam:   1-2 3 4 + Presentation:   Stable Evolving Unstable

11. Patient History Past Medical History History of current illness Prior level of function Physical characteristics Cognitive/Psychological context Social situation Living environment Personal factors

12. Examination Body structures and functions Musculoskeletal Neuromuscular Cardiovascular/Pulmonary Integumentary Orientation & Alertness Activity limitations Participation restrictions

13. Body systems (Exam) Musculoskeletal system Neuromuscular system Cardiovascular/Pulmonary system Integumentary system Orientation & Alertness

14. Documenting the Examination Activity Limitations: Mobility ADLs Self care Participation Restrictions: Home/Community Work/School P ublic access/transportation IADLs/other responsibilities

15. Presentation • Stable, uncomplicated, and predictable • Evolving, changing • Unstable, unpredictable, sig. safety concerns

16. Clinical Judgment: History + exam + presentation  clinical judgment  clinical decision making  value!

17. Avoiding miscoding Clear, objective documentation Lowest common denomenator Equal reimbursement No incentives with upcoding Use clinical judgment Consult the cheat sheet Consult colleagues/supervisors FREE CEUs on APTA, MedBridge sites

18. Things to consider.. Timing for complexity PT specialty Varying clinical judgment Not a perfect system Tx complexity levels

19. Dot phrase At date of evaluation, the medical and functional past medical history includes the below 2***3***4*** factors; influencing the patient's participation in the plan of care. 1. Diabetes, affecting tissue health 2. Chronic nature of pain, affecting recovery process due to physiologic changes to body 3. Unstable living situation, affecting ability to perform home program 4. Few friends/family in area for support 5. Psychological factors complicating overall health and recovery process 6. Cognitive factors Examination performed today identified the following 2***3***4*** body structures/functions to be addressed in therapy. 1. *** 2. *** 3. *** 4. *** Activity limitations include ***. Participation restrictions include ***. Based on standardized assessments, special tests, clinical judgment and stable***evolving***unstable*** clinical presentation, the patient is classified as minimally***moderately***highly complex. The developed plan of care is consistent with the problem(s) and needs of the patient, family and/or caregivers

20. Questions?

21. Case scenarios *Courtesy of Portland Providence Medical Center Rehabilitation Team*

22. References “Common Questions from our New PT and OT Evaluation Codes Webinar.” WebPT . Dec 2016. Print. < https://www.webpt.com/blog/post/common-questions-from-our-new-pt-and-ot-evaluation-codes-webinar > “ Documentation Tips for Physical Therapy Evaluation Code Selection.” American Physical Therapy Association . 2016. Print. < http://www.apta.org/uploadedFiles/APTAorg/Payment/Reform/DocumentationConsiderationsSupportingEvaluationCodeSelection.pdf> Elliot, Carmen “New CPT Evaluation Codes are Here.” PTinMotion . Feb 2017. Print. < http://www.apta.org/PTinMotion/2017/2/ComplianceMatters/> Evans, Wanda. “Compliance Matters: Documenting the New Evaluation Codes.” PTinMotion . March 2017. Print. < http://www.apta.org/PTinMotion/2017/3/ComplianceMatters/> Hibbert-Iaccobacci , Michele and Lindgren, Valerie. “New Physical Therapy Evaluation Codes for 2017: Moving Toward Value Based Payment.” Compliance Corner. Mitchell . Aug 2017. Print. < https://www.mitchell.com/mitchellnews/id/1495/new-physical-therapy-evaluation-codes-for-2017-moving-toward-value-based-payment >

23. References (cont.) Jannenga , Heidi. “What 500,000 Evaluative Notes Told Us About the New CPT Codes.” WebPT . Aug 2017. Print. < https://www.webpt.com/blog/post/what-500000-evaluative-notes-told-us-about-the-new-cpt-codes> Picard, Kathleen. “New Payment system: Evaluation Codes for Physical Therapy.” PowerPoint. Picard Consulting. 9/22/16. Print. <http://www.apta.org/uploadedFiles/APTAorg/Payment/Reform/NewPaymentSystemWebinar_EvalCodesforPhysicalTherapy.pdf> “Quick Guide to the 3 levels of Physical Therapy Evaluation.” American Physical Therapy Association . 2016. Print. <http://www.apta.org/uploadedFiles/APTAorg/Payment/Reform/NewEvalCodesQuickGuide.pdf> “Tiered Physical Therapy Evaluation and Reevaluation CPT Codes.” American Physical Therapy Association . 2017. Print. < http://www.apta.org/EvalCodes/ >