The decision between evaluation and re-evaluation for a patient can have a massive impact on medical billing. CPT code 97164 is used to report physical therapy (PT) re-evaluation services. This is one of the most frequently misunderstood and misapplied CPT codes.
Typically, this CPT code is reported to indicate a significant or meaningful change in a patient’s condition. This change requires formal reassessment and a plan of care (POC) revision.
However, both clinical justification and precise documentation are required before reporting this code to the payer. Accurate billing of CPT 97164 is essential for maintaining clean claims and reducing audit risks.
CPT Code 97164 – Description
According to the American Medical Association (AMA), 97164 falls under PT evaluations. Additionally, the official descriptor cited by the American Academy of Professional Coders (AAPC) for CPT code 97164 is:
“Re-evaluation of physical therapy established plan of care requiring these components: an examination including a review of history and use of standardized tests and measures; a revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.”
The above-mentioned description identifies three main components within the CPT code, which include:
- The treating therapist performs a re-evaluation, reviews the patient’s medical history, and administers standardized assessment tools and outcome measures.
- The findings are used to revise the POC based on standardized tests and measurable functional outcomes.
- This service typically involves 20 minutes of face-to-face time with the patient and/or family.
Important Details to Remember Before Billing 97164
Unlike timed therapy treatment codes, CPT 97164 is not selected based solely on meeting a 20-minute threshold. The code is mainly justified by:
- The revision of the POC
- The clinical need
Additionally, CPT code 97164 indicates re-evaluation and can be used for established patients only. The patient’s clinical status should demonstrate a significant change that warrants formal re-evaluation. Therefore, it should not be used for routine progress notes without POC modification.
Scenarios Where CPT Code 97164 is Applicable
Understanding when to report a re-evaluation code can be challenging, particularly for newer practices. So, here are three scenarios where CPT code 97164 applies accurately.
Sudden Functional Status Decline
Consider the case of a 67-year-old male patient who appears at the outpatient therapy clinic and is undergoing PT for right hip osteoarthritis. The physical therapist observes a sudden and unexpected decline in hip abductor strength after four weeks of therapy.
There is also a decline in functional ambulation, unanticipated in the original POC. Thus, the physical therapist:
- Carries out a formal re-evaluation.
- Revises the POC with updated goals.
- Repeats standardized outcome measures.
The re-evaluation is reported with CPT code 97164.
Surgery Mid-Episode of Care
Suppose a 56-year-old female patient appears at the hospital outpatient department as she is receiving PT for right knee osteoarthritis. The patient subsequently underwent a total knee arthroplasty. After the surgery, the physical therapist performs a re-evaluation to:
- Assess current functional status.
- Review post-surgical precautions suggested by the orthopedic surgeon.
- Revise the POC according to her new rehabilitation goals.
The service is then billed with CPT code 97164.
Quick Insight: Some commercial payers consider the post-operative period a new episode of care. They may require an initial evaluation code; thus, review the payer-specific policy before reporting the CPT code.
Anticipated Progress Failed
Imagine the case of a 78-year-old female patient receiving physical therapy. She has been experiencing balance deficits and is at risk of falls. She receives six weeks of treatment at an outpatient rehabilitation center.
However, the physical therapist determines that the patient’s progress has plateaued, as she did not achieve functional milestones. Since the milestones in the original POC were not met, the therapist conducts a formal re-evaluation.
The therapist identifies progress barriers and revises the POC with new short-term goals and a different approach for intervention. After the re-evaluation, the service is reported with CPT code 97164.
Applicable Modifiers for CPT Code 97164
CPT code 97164 is designated as an ‘always therapy‘ code and generally requires the appropriate therapy modifier. Therapy modifiers are required for all services billed under therapy services.
However, modifiers may apply differently based on the specific billing scenario and the payer requirements. The following table represents a breakdown of the modifiers applicable to CPT 97164.
| Modifier | Description |
|---|---|
| GP | Physical therapy services were rendered under a physical therapy POC. |
| CQ | All or part of the service was furnished by a Physical Therapist Assistant (PTA). |
| KX | Requirements mentioned in the medical policy have been met. |
| 59 / XE, XP, XS, XU | Physical therapy re-evaluation was distinct from other services performed on the same day. |
Note: Use the subset modifiers for 59 only when documentation supports distinct services and is permissible under payer policy.
CPT Code 97164 – Reimbursement Guidelines
Billing teams should understand the reimbursement requirements for CPT 97164. Here are the most crucial guidelines to remember:
Documentation Requirements
For CPT 97164, the medical record should include the following documents:
- A clear justification explaining why the re-evaluation was necessary.
- Latest and updated patient information and history, including patient-reported changes in function, symptoms, and goals.
- Detailed data from standardized assessment tools between evaluations to indicate the nature and extent of the change.
- A revised POC with assessment, changes, and intervention details.
- Documentation addressing the need for physical therapist expertise for reassessment and revision of POC.
Same Day Billing Rule
CPT code 97164 may be reported on the same date of service as treatment codes when the re-evaluation is:
- Separately identifiable
- Medically necessary
- Independently documented
Note: Always review payer-specific requirements because billing guidelines may be subject to change.
Plan of Care Requirements and Medicare Coverage
Medicare may cover CPT code 97164 when documentation supports a medically necessary re-evaluation. The re-evaluation should result from a significant change in the patient’s condition or treatment plan. However, a routine progress note and re-evaluation are different. The latter should include a comprehensive reassessment.
The reassessment must include evaluating progress with reference to current goals. It helps determine whether treatment or goals need to be updated or if the services should be terminated.
Important Note: No universal frequency limit applies to CPT 97164, as coverage frequency varies by payer and medical necessity.
Final Thoughts
Billing CPT code 97164 accurately requires a clear clinical trigger and thorough documentation. The billing teams should also have a solid comprehension of payer-specific rules to submit the claims precisely.
However, billing errors by an in-house team may lead to claim denial and delays. Fortunately, NeuraBill’s physical therapy billing services mitigate this challenge, resulting in effective billing.
