Posted on April 4, 2017 by Chapter Staff
Originally Published in HAPTA’s e-Newsletter, What’s HAPTAnin’ – April 2017

Now that the first 90 days of the New Year have passed, PT providers should have some sense of how payers are handling billing of the new 2017 CPT codes for initial evaluation (97161-low, 97162-moderate, 97163-high complexity) and reevaluation (97164). All HIPAA entities (Medicare, HMSA, UHA, HMAA, etc.) were required to use these new codes starting on January 1, 2017. We’ve heard of some HIPAA entities that were a little slow with getting the new codes up in their computer systems but most, if not all, have made the corrections by now.

The federal worker’s compensation program (Office of Workers’ Compensation Programs or OWCP) has decided to use the new IE/RE codes starting in January 2017. But state workers’ comp (DLIR), a non-HIPAA entity, did not. Motor vehicle (MVA) claims payers also fall under the category of non-HIPAA entity and have not adopted the new IE/RE codes.

However, DLIR instructed payers to pay claims submitted with both the new and old eval and reeval codes. Since the new codes are not listed in the fee schedule being used by DLIR, the system recognizes them as unlisted codes and pays for them at a rate of Medicare plus 10 percent:

Payment for (old evaluation code) 97001 on the current DLIR fee schedule is $100.62
vs. (new eval codes) 97161, 162, 163 – which is $88

Payment for (old reevaluation code) 97002 WC is $53.66
vs. (new reeval code) 97164 – which is $64.63

Another item we have heard about is that some workers’ comp carriers changed fee schedules to allow for all codes billed to be paid at the Medicare plus 10 percent level, perhaps in anticipation of the change proposed by DLIR to take place on 1/1/2017 that did not occur. So you may be seeing lower payments because of Medicare plus 10 percent adjustments. We have heard that Zurich and Sedgewick are requiring all providers to re-submit claims to get paid correctly because of this.

We want to hear from you if you have experienced any of these issues. Please e-mail

Patti Taira-Tokuuke, HAPTA Payer Relations/Reimbursement Committee Chair