CPT Code 97161 Physical Therapy Evaluation

CPT Code 97161 – Physical Therapy Evaluation (Low Complexity)

97161 CPT code description –

“PHYSICAL THERAPY EVALUATION: LOW COMPLEXITY, REQUIRING THESE COMPONENTS: A HISTORY WITH NO PERSONAL FACTORS AND/OR COMORBIDITIES THAT IMPACT THE PLAN OF CARE; AN EXAMINATION OF BODY SYSTEM(S) USING STANDARDIZED TESTS AND MEASURES ADDRESSING 1-2 ELEMENTS FROM ANY OF THE FOLLOWING: BODY STRUCTURES AND FUNCTIONS, ACTIVITY LIMITATIONS, AND/OR PARTICIPATION RESTRICTIONS; A CLINICAL PRESENTATION WITH STABLE AND/OR UNCOMPLICATED CHARACTERISTICS; AND CLINICAL DECISION MAKING OF LOW COMPLEXITY USING 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.” – Article ID A53309

When to choose CPT Code 97161 –

As indicated above, when your new patient presents with no personal factors and/or significant comorbidities that may impact the plan of care.

For example, in my outpatient physical therapy clinic, I often receive referrals for patients who may have comorbidities like diabetes, hypertension, and obesity, but these conditions are being medically managed and are stable.

The referral may be for persistent pain in a shoulder or back which is limiting my patient’s ability to perform daily tasks either in a pain-free manner or at all.

I address body structure and function, activity limitations due to impairments, and participation limitations, but in general, my patient has been experiencing relatively stable symptoms that are either unchanging or slowly getting worse.

In the case of a low complexity initial physical therapy evaluation, my patient is often driving independently, bathing, grooming, and dressing. My patient is often active at home and in the community. He is managing finances and active with recreational activities and social gatherings.

Billing CPT Code 97161 – Reimbursement Rates in 2022

* Click here to see the Top 5 Highest Paying Physical Therapy Codes

What the following video to learn how you can search the CMS Physician Fee Schedule in your state.

CPT Code 97161

Required Documentation Elements for a Low Physical Therapy Evaluation

There are two factors to consider when determining CPT Code 97161 Documentation Requirments.

1.) Look at the definition of the specific CPT code.

• Include 1-2 elements for the list provided.
• Determine the stability of the symptoms or condition.
• Determine the lack of complexity and lack of comorbidities.

2.) Understand the Medicare requirements for a physical therapy evaluation. Reference CMS Chapter 15 Section 220.3 Documentation Requirements for Therapy Services

Examples of Documentation:

Does Medicare Pay More for Higher Complexity Physical Therapy Evaluations

No. Medicare and most other third-party payers do not reimburse higher rates for higher complexity CPT codes.

CPT codes 97161, 97162, and 97163 are all commonly reimbursed at the same rate as of the 2022 physician fee schedule.

Additional Resources:

Visit the APTA Physical Therapy Evaluation Reference Table PDF

This handy guide lists the 4 components required to determine the evaluation complexity level. 

1. History
2. Examination of body systems
3. Clinical Presentation
4. Clinical Decision Making