Billing, reimbursement, and code complexities
To bill or not to bill. That seems to be the question surrounding 97750 lately when it comes to Work Hardening and Work Conditioning Evaluations. In my clinical experience working in Illinois and Wisconsin, I have always billed Physical Performance Test and Measure for my evaluations and 97545/97546 specifically for treatment. Lately, there seem to be some differing opinions and movement away from that concept.
When to use which code
First, let’s take a look at the applications where 97750 is typically utilized. Most commonly, this code is used for Functional Capacity Evaluations and as such it is often referred to as the FCE code. However, this is incorrect as the code is defined as Physical Performance Test and Measure. Work Harding and Work Conditioning Evaluations are very similar to Functional Capacity Evaluations regarding their content. Although Work Hardening and Work Conditioning Evaluations are generally shorter and do not focus as much on the client’s maximum capacity, they still contain many of the same basic components. Due to this reason and the fact that a Work Hardening and Work Conditioning Evaluations is not treatment, it would seem to suggest that billing should be like an FCE.
On the other hand, we can review 97545. This is often utilized for the first two hours of each client’s Work Hardening and Conditioning session. Objectively, an evaluation is not the same as a WH/WC treatment session and therefore should not be billed the same. I cannot think of another scenario in Physical or Occupational Therapy where a clinician would build a treatment code for an evaluation. However, I have been hearing from many customers that they are receiving denials due to using 97750 for their evaluations and are being told to bill 97545 instead. In most cases my suggestion has been to bill 97750 by default, and in cases where that CPT code is denied, to bill 97545 secondarily.
Reimbursement rates & the effect on evaluations
Now, let’s take a moment to review the differences in reimbursement between these codes and what may be motivating the payers to transition toward this approach. In this example, I am going to utilize Wisconsin as my state where 97750 is billed as approximately $90 per unit and 97545 is billed as around $200 per unit. Work Hardening and Conditioning Evaluations take two hours to complete in most cases. Therefore, you would bill eight units of 97750. This means the charge for the skilled initial evaluation would come to approximately $720. However, based on this recent transition towards billing 97545, that would only reimburse $200. As you can see, this is a large decrease in reimbursement for this service.
My concern with this transition is that because of lower reimbursement, clinicians are de-incentivized to spend high-quality time with their patients during the initial evaluation. Instead of billing per 15-minute increment, up to a maximum of two hours, providers may spend as little as 30-45 minutes with their clients and bill the same code as providers who spend the entire two hours performing a detailed evaluation. This would then trickle down and could have a negative impact on the overall program due to not having the necessary information on day one to establish a customized, high-level plan for each client. All of this could lead to longer durations, more visits, and in turn, cost the payer more in the end.
At this point, it is unclear what the long-term effects will be, but we are seeing this gradual trend with our customers across the county. We will continue to monitor this issue and look toward future data to see if our billing recommendations need to be adjusted and keep you updated with the latest information.
Have a question regarding billing codes and reimbursement rates? Reach out to Eric Ahonen, Vice President of Business and Network Development, by email at firstname.lastname@example.org.