Quite Simply, It’s Complex: The Truth About Four New PT Evaluation Codes


Just four new codes…seems easy, right? The truth is, this new evaluation code law for 2017 has a little more going on just below the surface. The standards of an evaluation will remain the same. The real curve-ball here is the newly added system to classify complexity. Physical therapists have four components to consider, and each level of complexity has criteria for elements from each. (Are you an Occupational Therapist? Click here) Here’s a quick breakdown:

1. Patient History

This includes comorbidities, their functioning level prior to what led them to seek care, relevant treatment approaches in the past, and various factors such as medications, work status, social history, and more. The key here is to only consider aspects of the patient’s history that directly impact the plan of care now.

2. Examination

Includes body structure and function, activity limitations, and participation restrictions. The last two might seem a little redundant, but there are subtle differences between them. The ICF defines activity limitations as “difficulties an individual may have in executing activities” and participation restrictions as “problems an individual may experience in involvement in life situations”. Here’s a post for reference on what the ICF is all about. Activities and participation include- but are not limited to- mobility, self-care, domestic life, interpersonal interactions and relationships, and civic life.

3. Clinical Presentation


The patient is stable and uncomplicated. This is your straightforward athlete with an ankle sprain- their ankle hurt the worst at time of injury, is getting better, and you can expect it to get better over time.

The patient has evolving clinical presentation with changing clinical characteristics. This patient could be someone who began treatment with neck and upper back pain and now also has numbness in the right arm and hand. The symptoms are evolving and definitely have the potential to get worse.

The patient has evolving clinical presentation with unstable and unpredictable characteristics. Take our back pain and hand numbness patient from a moment ago, and throw in orthostatic hypotension. There is a risk every time you have the patient change positions that their blood pressure can bottom out, ergo their blood pressure is unstable and unpredictable

4. Clinical Decision Making

The final piece of the puzzle. This is your judgement as a therapist based on the big picture of the patient regarding their treatment plan. It can be of low, moderate, or high complexity, and the decision must be made using a “standardized patient assessment instrument and/or measurable assessment of functional outcome”.

Once you throw in the different requirements for each complexity level, this new coding system can get a little convoluted. That’s why we want to give you all the resources you need to be successful in 2017.

Malcolm L. Bond, Ph.D.  Cedaron’s Founder and Chief Scientist