PT, OT Evaluation Codes Get an Upgrade – New Therapy Caps

2017 Changes: Double Check Your Code Status

By now, your billers should be thoroughly familiar with the four new PT and/or four new OT codes for 2017. If not, you may be seeing an increase in rejections, denials, and—possibly—collections.

The new codes replace the somewhat vague “PT evaluation” and “OT evaluation” with more specific evaluation types, including the length of time the evaluation took. In this post, we’ll outline the new codes and the codes they replaced, then offer some suggestions on evaluating your progress on the new rules.

New PT and OT procedure codes

Here are the codes that should have been replaced:

  • 97001 – PT evaluation
  • 97002 – PT re-evaluation
  • 97003 – OT evaluation
  • 97004 – OT re-evaluation

Here are the PT replacement codes:

  • 97161 – PT evaluation low complexity, 20 min
  • 97162 – PT evaluation moderate complexity, 30 min
  • 97163 – PT evaluation high complexity, 45 min
  • 97164 – PT re-evaluation est. plan care

Here are the OT replacement codes:

  • 97165 – OT evaluation low complexity, 30 min
  • 97166 – OT evaluation moderate complexity, 45 min
  • 97167 – OT evaluation high complexity, 60 min
  • 97168 – OT re-evaluation est. plan care

Use of discipline-specific modifiers when billing Medicare

GN (speech language pathology), GO (occupational therapy), and GP (physical therapy) modifiers have been in effect since September 1, 2016. Therapy codes aren’t payable without one of these modifiers.

Thus, the GP modifier applies to the four new PT codes, indicating services delivered under an outpatient physical therapy plan of care. The GO modifier applies to the four new OT codes, indicating an outpatient occupational therapy plan of care.

New therapy caps

Medicare rules regarding therapy caps have also changed for 2017. There’s a $1,980 cap for PT and speech language pathology combined (up from $1,960 in 2016 and $1,940 in 2015, so in keeping with the $20-rise-per-year trend). There’s also a $1,980 cap for OT.

Note that deductible and co-insurance amounts count toward the amount applied to the limit. Also, there’s an exemption process through the end of 2017 for when medical necessity requires services beyond the cap. However, a manual medical review is required once expenses reach $3,700.

To bill under the exemption, modifier KX must be used. According to CMS, when you use the KX modifier, you are attesting that the services you provided are reasonable and necessary and that there is documentation of medical necessity in the beneficiary’s medical record.

Gaining efficiency

Here are a few ways to evaluate your progress on the new rules.

  1. Run procedure reports for dates of service post-January 1 to ensure claims don’t include any old codes (97001, 97002, 97003, 97004).
  2. Run procedure reports to identify any for which no GO or GP modifier was assigned.
  3. Review claims that were denied or rejected for reasons related to absence of modifier on evaluative procedure codes.
  4. Use your software to set procedure-code macros for evaluative procedure codes to automatically assign the right modifier.
  5. Leverage any therapy-limit calculators and alerts that are built into your medical billing application.

Hopefully, your practice’s transition to the new codes was smooth. If you have suggestions or tips you’d like to pass along to others on this topic, email your ideas to We’d love to feature you as an expert or have you contribute to one of our Therapy Tips articles.

As you know, these codes and regulations are subject to change, and the details for how to use all of the codes and modifiers are dependent on specifications from the individual payers. References for this article and additional helpful resources are below:

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Last Updated on November 25, 2021