Physical therapy (PT) evaluations are among the hardest to bill. Why? They require comprehensive documentation and are bound by numerous limitations. Keeping track of these limitations and requirements can be confusing, which leads to claims denials.
A frequently used PT code for face-to-face evaluation is CPT code 97161. In this guide, we have discussed everything you need to know to bill this code correctly. So, let’s start.
CPT Code 97161 – Description
CPT code 97161 is defined as:
Physical therapy evaluation: low complexity, 20 minutes are spent face-to-face with the patient and/or family.
The definition seems simple enough. However, billing this code is more complex than it looks. Firstly, let’s discuss some additional requirements that are necessary for the use of 97161:
- History: No personal factors and/or comorbidities that impact the plan of care.
- 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.
- Clinical Presentation: The patient is clinically stable with no evolving complications or unstable symptoms that could complicate treatment planning.
- Clinical Decision Making: Low complexity using standardized patient assessment instruments and/or measurable assessment of functional outcome.
Additionally, the entire evaluation session must last 20 minutes. Moreover, the session must be conducted face-to-face with the patient. Please note that CPT code 97161 is used only for initial evaluations and cannot be used for re-evaluations.
Scenarios Where CPT Code 97161 is Applicable
Let’s discuss some details about when you can use CPT code 97161.
Post-Surgical Knee Recovery
Suppose a 28-year-old man who recently had a knee surgery visits a physical therapist. However, ever since the surgery, he has been experiencing mild knee stiffness and slight weakness when climbing stairs. He shares that the pain is manageable with OTC medications, and his walk is stable.
The physical therapist performs a detailed assessment of the knee and confirms that there are no post-surgery complications. He assesses the range of motion, basic strength testing, and functional movements. He, then, determines that this type of pain and stiffness during movement is normal after such surgery. This initial assessment can be billed with CPT code 97161.
Lower Back Strain
A 40-year-old teacher has mild lower back discomfort after helping move classroom furniture. Ever since the incident, she has been feeling tightness and occasional aching in her lumbar region, particularly when sitting for extended periods. She visits her physical therapist. Upon inquiry, she reveals that she does not have any history of back pain or musculoskeletal problems.
The therapist examines her posture, basic range of motion, and performs simple movement tests to identify areas of restriction. The therapist can bill this simple PT evaluation with CPT code 97161.
Applicable Modifiers for CPT Code 97161
Billing physical therapy codes can be confusing. A lot of different situations may arise during the evaluation that require modifiers. The following are some commonly used modifiers with CPT code 97161:
| Modifier | Description | Usage |
|---|---|---|
| 59 | Distinct Procedural Service | Indicates that the procedure is distinct and separate from other services performed on the same day. |
| GP | Therapy Plan Identification | Indicates services provided under a specific physical therapy plan of care. |
| GN | Speech Therapy Designation | Designates speech therapy plan services. |
| GO | Occupational Therapy Designation | Used when occupational therapy services are involved. |
| XU | Unusual Non-Overlapping Service | This modifier indicates that the service does not overlap with the usual components of the primary service. |
CPT Code 97161 – Billing & Reimbursement Guidelines
Just knowing the details of CPT code 97161, its best use cases, and applicable modifiers is not enough to guarantee a clean claim submission. You must also be aware of the most essential billing guidelines and reimbursement rates. The following are some important points that you must consider while filing claims:
Provide Comprehensive Documentation
Successful reimbursement depends on justifying the medical necessity. To prove that the PT evaluation was medically necessary, you must provide detailed documentation with your claims. For 97161, the following details are required:
- Objective, measurable documentation of patient impairments and how they affect Activities of Daily Living (ADLs)/Instrumental Activities of Daily Living (IADLs), leading to functional limitations.
- In your claims, clearly describe what brought the patient to therapy. This includes noting the changes in their normal function.
- Specify which part of the body is affected.
- Medical history and previous medications.
- If treatment was provided recently, document why additional PT is necessary.
- Summarize the therapist’s analysis.
- Signature and credentials of the therapist or physician.
Follow the Key Billing Guidelines
- Bill the initial evaluation (97161) only once per therapy discipline during an episode of care.
- If the assessment takes multiple days to complete, bill it as one unit only on the day it is finished.
- Testing codes (CPT 95851-95852, 97750, 97755) are already included in the evaluation.
- Screenings cannot be billed as evaluations.
Follow the Usage Guidelines
When You Can Use CPT 97161
- Brand new patients: Someone who has never received therapy before.
- Returning patients: Someone who was previously discharged from PT and is coming back (even for the same problem).
- New unrelated condition: A current therapy patient develops a completely separate, unrelated problem
When You Cannot Use CPT 97161
- For follow-up visits or re-checking the same condition (use re-evaluation codes like 97164 instead).
- For conditions related to what you are already treating.
- Multiple times during the same episode of care, unless it is truly a new, unrelated condition.
Important Points To Consider
- One comprehensive evaluation should cover all related conditions at once.
- You don’t need separate evaluations for multiple related problems.
Confirm the Medicare Reimbursement Rate
The reimbursement amount for CPT code 97161 varies for each MAC locality. The national average reimbursement amount for 97161 is $98.01 for non-facility settings.
You can check the exact reimbursement rate for your MAC locality via the PFS Lookup Tool.
Wrapping Up
Let’s wrap up everything. In this guide, we have simplified CPT code 97161 to the best of our ability. The code refers to an initial physical therapy evaluation of 20 minutes that is conducted face-to-face and involves low complexity medical decision-making. For proper reimbursement, use the correct modifiers and provide comprehensive documentation with your claims.
However, if you are facing frequent denials, it is better to let experts handle your billing. Many medical billing companies, like MediBillMD, offer specialized physical therapy billing services.
