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
Ohio Medicare CGS 2022 Physician Fee Schedule: |
| CPT Code 97161 Reimbursement Rate: $98.60 |
New York 2022 Medicare Physician Fee Schedule: |
| CPT Code 97161 Reimbursement Rate: $99.73 |
California 2022 Medicare Physician Fee Schedule: |
| CPT Code 97161 Reimbursement Rate: $105.93 |
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.
- History
- Examination of body systems
- Clinical Presentation
- Clinical Decision Making
How to create a superbill for cash based therapy, out of network claims Office Ally Practice Mate
The CMS 1500 form is the gold standard for superbills. If you are giving cash based clients a superbill or helping clients submit out of network claims this tutorial will walk you through the entire process from start to finish for using a FREE Practice Mate account to create and print a CMS 1500.
Medicare Physical Therapy Claim and Reimbursement Analysis – How to create a profitable practice
Medicare reimbursement for physical therapy has been on the decline for several years now and with the proposed reductions coming in the next year physical therapy clinic owners are looking for new business models. The way it has always been done isn’t going to bring you success in your physical therapy practice moving forward.
How much does medicare part b pay for physical therapy
If you want to learn how to look up the Medicare CMS Physician Fee Schedule for 2020 and specifically for physical therapy, occupational therapy, or speech language pathology, WATCH THIS VIDEO.
Telehealth – Using ScreenCapture, Canva, and A Digital Goniometer To Measure ROM (FREE)
Telehealth for physical and occupational therapy has been growing in popularity lately. Along with this growth, therapists are looking for new and easy to use tools. This simple goniometer can be added to your screen capture to measure joint range of motion.
Medicare Guidelines for Billing Therapeutic Exercise 97110 PT, OT in 2020
“Many therapeutic exercises may require the unique skills of a therapist to evaluate the patient’s abilities, design the program, and instruct the patient or caregiver in safe completion of the special technique. However, after the teaching has been successfully completed, repetition of the exercise, and monitoring for the completion of the task, in the absence of additional skilled care, is non-covered. For example, as part of the initial therapy program following total knee arthroplasty (TKA), a patient may start a session on the exercise bike to begin gentle range of motion activity. Initially the patient requires skilled progression in the program from pedal-rocks, building to full revolutions, perhaps assessing and varying the
seat height and resistance along the way. Once the patient is able to safely exercise on the bike, no longer requiring frequent assessment and progression, even if set up is required, the bike now becomes an “independent” program and is no longer covered by Medicare.”
