Unsure how to bill physical therapy (PT) re-evaluations? We have got you covered. The line between CPT codes for physical therapy evaluations, re-evaluations, and unlisted codes is not clear. It leads to confusion, billing mistakes, and ultimately claim denials.
That’s why we have created this detailed guide on CPT code 97164, which is a frequently used code for PT re-evaluations. By the end of this guide, you will know when and how to use this code in your billing.
CPT Code 97164 – Description
CPT code 97164 is defined as:
“Physical therapy re-evaluation of an established plan of care, typically 20 minutes.”
The definition seems simple enough. However, what many billers miss while filing claims is that this definition is incomplete. Based on the Centers for Medicare and Medicaid Services (CMS) guidelines, for 97164 to be valid, the following three requirements must be met:
- The re-evaluation must include a thorough review of the patient’s medical history. Additionally, the examination should include standardized tests and measures that are appropriate to the patient’s condition and the outcome of the treatment.
- Based on the examination findings, the therapist must develop or significantly modify the existing plan of care. This revision should utilize standardized patient assessment instruments or measurable functional outcome assessments to justify the changes in treatment approach.
- Lastly, the physician must spend 20 minutes with the patient face-to-face.
Scenarios Where CPT Code 97164 is Applicable
Knowing exactly when to apply this code can prevent a lot of billing errors and ensure proper reimbursement. Let’s take a quick look at when CPT code 97164 is appropriate and when it is not.
Development of Related Conditions
You can use code 97164 when a patient develops a new condition that is related to the original diagnosis he is being treated for. For example, if an elderly man is getting therapy for lower back pain, but also develops hip pain due to compensatory movement patterns, the physician may use 97164 for evaluating this new related condition and how it affects the previous treatment plan.
Unexpected Clinical Changes
Another common use of this code is when a patient experiences unexpected improvement, decline, or plateau in the functional status. To study this sudden change and adjust the treatment accordingly, the physician might need to perform a re-evaluation. For example, a patient recovering from knee replacement surgery who suddenly develops complications or demonstrates faster-than-expected progress may require re-evaluation.
Treatment Plan Ineffectiveness
Another scenario in which CPT code 97164 can be used is when a treatment plan is not working as the physician expected, or the results are not satisfactory. This may require a comprehensive reassessment to modify the therapeutic approach.
Applicable Modifiers for CPT Code 97164
Filing an insurance claim is more than just using the correct code. That’s especially true for physical therapy re-evaluations. You must justify why the re-evaluation was necessary and the circumstances in which it was performed. Modifiers serve this exact purpose. The following are some modifiers that you can use with CPT code 97164:
| Modifier | Description | When to Use |
|---|---|---|
| 59 | Distinct Procedural service | When 97164 is performed on the same day as other therapy services, that might be bundled together. |
| GP | Physical Therapy Services | Used when the service was delivered under an outpatient physical therapy plan of care. |
CPT Code 97164 – Billing & Reimbursement Guidelines
Attention to detail is vital when reporting CPT code 97164. Even small mistakes can lead to claim denials. To improve your claims acceptance rate, follow these guidelines.
Provide Comprehensive Documentation
Provide comprehensive documentation with CPT code 97164 claims to justify its necessity. Documentation becomes more crucial for re-evaluation codes than initial evaluations, so append everything relevant. As per the CMS guidelines, the following details are essential:
- Clear explanation of new findings or significant changes
- All applicable components of an initial evaluation, including:
- Presenting condition/complaint and reason for re-evaluation
- Diagnosis and description of any new or changed problems
- Subjective complaints with dates of onset or change
- Relevant medical history and comorbidities
- Prior diagnostic testing results (if relevant)
- Documented changes in range of motion, strength, balance, pain levels, or ADL capabilities
- Progress toward current goals or lack thereof
- Clinical reasoning supporting continued therapy, modifications, or discharge
- Updated prognosis and plan of care with revised goals
- Signature and credentials of the therapist completing the re-evaluation
Bill One Unit Per Visit
Billing limitations bind code 97164. So, always bill one unit per visit, regardless of actual time spent.
Understand When Not to Use CPT Code 97164
Do not use this code for:
- Routine Assessments: Healthcare providers must understand that CPT code 97164 must not be used for routine progress assessments or standard treatment sessions. Medicare states that ongoing progress assessments are not separately reimbursable as re-evaluations.
- Unrelated Conditions: If a patient develops an unrelated condition requiring evaluation, providers should use an initial evaluation code (97161-97163) rather than a re-evaluation code. That’s because the new condition must be treated as a separate diagnostic concern and may have a completely different treatment than the first one.
Confirm the Medicare Reimbursement Rates
Medicare currently pays around $67.60 nationally for CPT code 97164 in non-facility settings, according to the 2025 Physician Fee Schedule.
However, this amount is the national average, and the actual payment varies for each MAC locality. You can check the exact reimbursement rate for your MAC locality via the PFS Lookup Tool.
Wrapping Up
Finally, we have reached the end of this guide. It is a lot of information to absorb, so let’s do a quick recap of the essential points.
CPT code 97164 is for billing a physical therapy re-evaluation, which typically takes 20 minutes. However, for the code to be valid, the re-evaluation must fulfill the three requirements that we mentioned in the code description. Additionally, for fair reimbursement and to avoid claim denials, you must provide comprehensive documentation with your claims and append appropriate modifiers (when required).
If you need help with medical billing, consider consulting our billing experts at MediBillMD. Our experts have decades of experience in providing premium physical therapy billing services.
