CPT code 97162
CPT Code 97162 or “moderate complexity evaluation” is one of the tiered steps required for new client evaluation since 2017. While these codes are not currently tied to tiered reimbursement, accurate reporting is still important. If you haven’t taken a look at our first post on the low complexity evaluation code, 97161, that is a great place to start.
In that post we review the purpose and practice of CPT codes, components of a thorough initial evaluation as well as introduce the low complexity evaluation code 97161. In this article we will expand on the second tier of evaluation codes, specifically CPT code 97162.
CPT code 97162: Moderate complexity evaluation
The chart below outlines the requirements for using each of the evaluation codes. In order to bill using the moderate complexity CPT code 97162, the client must meet or exceed all of the criteria for history, examination of body systems and clinical presentation in the moderate column. If even one of the components meets the criteria for low complexity, you must bill it as a low complexity evaluation.
CPT Codes | 97161 Low complexity | 97162 Moderate complexity | 97163 High complexity |
|---|---|---|---|
History: Number of personal factors and/or comorbidities relevant to plan of care | None | 1-2 | 3 |
Examination of Body systems: Elements include body structures and functions, activity limitations, and/or participation restrictions | Addressing 1-2 elements | Addressing 3 elements | Addressing 4 or more elements |
Clinical Presentation | Stable | Evolving | Unstable |
Component 1: History
CPT code 97162 and comorbidities
Clients considered moderate in the history category are those that have 1-2 personal factors or co-morbidities that may complicate the plan of care. Co-morbidities are other health conditions that might impact a person’s ability to participate in, follow or respond to your plan of care.
Some examples of comorbidities could include diseases for which a person undergoes regular medical care which might interfere with their ability to attend appointments. A condition that impacts their ability to heal like diabetes may prolong or extend a treatment plan. Even a comorbid condition like rheumatoid arthritis may impact how a client responds to your care.
Not every comorbidity is relevant to the plan of care so be sure to consider the relevance of these comorbidities before selecting the moderate category.
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CPT code 97162 and personal factors
Personal factors arise from an individual's background. They are not a part of the original health condition nor a part of their external environment but can have a significant impact (positive or negative) on how they participate in or respond to therapy.
Gender, age, race, education level, fitness level, habits, beliefs and social background are examples of personal factors. Once again, a personal factor must impact the plan of care in a way that increases complexity in order for it to be considered as part of these criteria.
An individual who does not believe in modern healthcare or who has had a negative experience with physical therapy in the past has a relevant personal factor. Similarly, a person who has never exercised and does not see the benefit of following a home exercise program also has a relevant personal factor.
Component 2: Examination of body systems
A person who meets the moderate level criteria for this component is one whose initial evaluation required the examination of at least three body systems in order to determine their need for therapy and construct a comprehensive plan of care.
This examination can occur at the body structure/function impairment level, activity limitation or participation restriction level.
Relevant systems that can affect, cognition, communication include the:
- Cardiorespiratory system
- Integumentary system
- Musculoskeletal system
- Neuromuscular system
Examples
If a client with shoulder pain required examination of only the musculoskeletal system and perhaps one activity-level task, they would not meet the criteria for moderate complexity CPT code 97162.
A client being seen for a stroke who requires monitoring of their vitals, examination of their neuromuscular system as well as assessment of activities like walking, getting up from the floor and transferring would meet the criteria for moderate complexity CPT code 97162.
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Component 3: Clinical Presentation
Clinical presentation is often the criteria that determines whether an evaluation is low, moderate or high. Because a client needs to meet or exceed all criteria under the CPT code 97162 category in order to be considered of moderate complexity, in addition to relevant comorbidities and personal factors as well as three body systems that require examination, their clinical presentation must be evolving.
This means that their health condition is evolving or the impact of the health condition on their function is evolving and worsening. An individual with many relevant comorbidities and several pertinent body systems but whose presentation has been stable for a while does not meet the criteria for a moderate complexity and CPT code 97162 should not be considered.
Clinical presentation examples
For example, an individual with Parkinson’s who’s disease presentation and level of function is impaired but relatively unchanged for some time, would be considered to have a stable clinical presentation. One who’s presentation has been steadily worsening as their Parkinson’s is actively progressing, however, could be considered to have an evolving presentation.
Similarly, an individual with worsening heart disease or cancer or progressing ALS could be considered evolving not stable. Even a client who has pain which has been worsening and progressively affecting more areas of function may be considered evolving.
As you can see, there is quite a bit to consider when deciding which evaluation code to select. One quick tip is to consider the clinical presentation first. If the client’s clinical presentation has been stable there is no need to consider any other code but 97161–low complexity.
If, however, you deem their presentation as evolving or unstable it is time to look at the other criteria to make the best choice and CPT code 97162 may be more appropriate.
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