What is a Physical Therapy Reevaluation CPT Code 97164?
According to Medicare A53309 CPT Code 97164:
“Re-evaluations are separately reimbursable when the medical record supports that the patient’s clinical status or condition required the additional evaluative service. When medical necessity is supported, a re-evaluation is appropriate and is separately billable for:
• A patient who is currently receiving therapy services and develops a newly diagnosed related condition e.g., a patient that is currently receiving therapy treatment for TKA. During the episode of care, the patient develops wrist pain. The clinician determines that the wrist pain is due to use of a walker which the patient is using as a result of the TKA. In this scenario, the wrist pain is a condition that is related to the TKA. Therefore, it is reasonable for the clinician to provide a re-evaluation of the patient due to this related condition.
• A patient who is currently receiving therapy services and demonstrates a significant improvement, decline, or change in condition or functional status which was not anticipated in the plan of care and necessitates additional evaluative services to maximize the patient’s rehabilitation potential.
Note that routine continuous assessment of the patient’s expected progress in accordance with the plan of care is not considered to be a medically necessary service and is not separately reimbursable as a re-evaluation. Limited routine assessment (e.g., for progress reporting) is a component of ongoing therapy services an is included in services and procedures.”
Physical Therapy Reevaluation CPT Code 97164 vs Physical Therapy Progress Report
A PT progress report is not a separately payable event. A progress report is a required element of documentation and requirement of reimbursement.
In my experience, too many therapists treat a progress report like a reevaluation despite the published Medicare example is CMS Chapter 15.
Related Article: Can a physical therapist bill Medicare for a progress note?
When Should A Physical Therapist Perform a Physical Therapy Reevaluation?
The most common time in which a physical therapist would perform and bill for a physical therapy reevaluation using CPT Code 97164 is when there is a significant and unexpected change in status.
Significant and Unexpected Change in Status
According to Medicare CMS Chapter 15 page 159 “Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, or decline, or change in the patient’s condition or functional status that was not anticipated in the plan of care.”
The key word in that quote from Medicare is “NOT anticipated”.
Improvement, plateaus, and exacerbations are all expected within a typical physical therapy plan of care. An example of an unanticipated change in status would be a patient who was evaluated for left hip pain attributed to osteoarthritis. Then after 2 weeks of therapy, signs, and symptoms suggest a possible femur fracture. Imaging confirms femur fracture which was an unanticipated change in status for the same condition of ICD-10 code M25. 551.
When Should A Physical Therapist Bill CPT Code 97161 Instead of CPT Code 97164?
To build on the example mentioned above. If a physical therapist evaluated a patient for right hip pain under ICD 10 diagnosis code M25.551 and later found out that the same patient was experiencing left shoulder pain, this therapist would NOT bill a reevaluation code but instead bill a physical therapy evaluation code.
The shoulder pain was unanticipated, but it is not directly related to the hip pain. It is a new treatment diagnosis and therefore requires a new evaluation.
• Current Procedural Terminology (CPT) Manual
• CMS Internet Only Manual (IOM), Medicare Benefit Policy Manual , Publication 100-02, Chapter 15, Sections 220(A), 220.3.5(A), 230.1.
• IOM, Medicare Benefit Policy Manual, , Publication 100-02, Chapter 16, Section 150