Issue #17-05

The Department of Health is implementing internal system updates to accommodate changes to physical and occupational therapy evaluation and re-evaluation billing codes. CPT codes 97001-97004 are replaced with 97161-97168 for dates of service on and after January 1, 2018. See Table 1 in this alert for the new CPT and rate codes for SSHSP billing.

As stated in Medicaid Alert #16-08, changes to the SSHSP CPT code list were necessary to comply with physical and occupational therapy evaluation and re-evaluation CPT code changes made in January 2017 by the American Medical Association (AMA).  The new evaluation codes reflect 3 levels of patient presentation: low-complexity, moderate- complexity, and high-complexity.  However, there will be no change in the reimbursement rates for physical and occupational therapy evaluations and re-evaluations.  Service providers should refer to their professional associations (e.g., The American Occupational Therapy Association, Inc. and the American Physical Therapy Association) for guidance on the use of the new codes.

Prior to January 1, 2018 each enrolled SSHSP billing provider should receive correspondence from CSRA on behalf of the NYS Department of Health (DOH) indicating that the new billing codes have been added to their Medicaid enrollment file.  The new codes must be used when billing SSHSP Medicaid for evaluations and re-evaluations conducted on and after January 1, 2018.

SSHSP billing providers will need to work with their software vendors and billing agents to update the CPT codes in the specific software applications used to support SSHSP billing activities.  Physical therapy and occupational therapy evaluations and re-evaluations with a date of service prior to January 1, 2018 are still to be billed using CPT codes 97001-97004 with their associated rate codes.

Table 1:  Crosswalk of Billing Code Changes Effective Date of Service (DOS) January 1, 2018 for SSHSP Physical and Occupational Therapy Evaluations and Re-evaluations

Billing providers should contact the Department of Health at (518) 473-2160 or email sshsp@health.ny.gov if they do not receive a letter by January 1, 2018 stating their billing codes have been updated.

In addition, the SSHSP CPT Code list (Handout 5) will be revised with the updated physical and occupational therapy evaluation and re-evaluation CPT codes once the process is complete.

If you have any questions or comments regarding this Alert, please contact the NYS Department of Health at (518) 473-2160 or at SSHSP@health.ny.gov or the NYS Education Department, Medicaid Unit at medined@nysed.gov.