Before a physical therapist plans a treatment course or provides any physical therapy service to a patient, he analyzes the patient’s physical health. This initial physical evaluation involves various levels, like assessing the range of motion, measuring the strength of multiple muscles and limbs, or testing daily functions.
Whenever the physician conducts a moderately complex physical therapy evaluation before recommending therapeutic exercises and treatment options, he reports the procedure using CPT code 97162. But what constitutes a moderately complex evaluation? Continue reading to find out.
CPT Code 97162 – Description
CPT code 97162 is used to bill a physical therapy evaluation of moderate complexity. The face-to-face evaluation lasts around 30 minutes and includes several steps and tests.
For example, the physician notes the patient’s history, observes the patient’s current condition, and thoroughly examines 3 or more bodily functions, such as joint flexibility, gait, mobility, muscle strength, and neurovascular function. After a thorough assessment, the physician performs medical decision-making of moderate complexity.
The purpose of this evaluation is to ensure that the therapist comprehensively assesses a patient’s situation, enabling the creation of a more customized treatment plan.
Scenarios Where CPT Code 97162 is Applicable.
The following are some practical examples that highlight the appropriate application of CPT code 97162.
Chronic Back Pain
Suppose a 40-year-old man who is slightly obese suffers from chronic low back pain that is affecting his movements and mobility, like sitting and walking. He visits a physiotherapist in his neighborhood and tells him about his pain points. Before curating a treatment, the therapist performs an assessment, which includes noting the patient’s complete history and evaluating the patient’s posture, range of motion, muscle strength, and functional abilities. This evaluation lasts 25 minutes and includes a moderate level of medical decision-making. So, the therapist can bill this session with CPT code 97162.
Minor Injury
Imagine a male in his late teens playing soccer and spraining his left foot. The patient complains of experiencing pain when running and jogging, even after resting and recuperation. As his foot swells after a tiring day at school, he consults a physical therapist.
The therapist takes a history of his past injuries, compares the range of motion inside and outside, and tests the leg’s muscular strength. The evaluation reveals that the patient suffers from dyspnea, which could restrict the course of treatment. Since the session involves a moderate level of medical decision-making, the therapist can apply CPT code 97162 for billing and reimbursement.
Post-Surgical Recovery
Suppose a 52-year-old woman recently underwent a knee replacement surgery. To heal from her surgery and increase her movement and mobility, she goes to a physiotherapist. The therapist performs a moderate complexity evaluation of her muscle strength, functional mobility, joint flexibility, and range of motion. The assessment helps in creating a customized rehabilitation plan to restore her mobility, strength, and function, while also preventing injuries in the future. So, the physician can bill the service with CPT code 97162 as he has performed a level 2 physical therapy evaluation for exactly 30 minutes.
Applicable Modifiers for CPT Code 97162.
Modifier GP is one of the essential modifiers that you must append to CPT code 97162. Other than this, you can append modifier 25 to highlight the distinctiveness of the service. Consider the following details about both modifiers to avoid their misuse.
Modifier GP
The GP modifier indicates that the service was provided as part of an outpatient physical therapy plan. Medicare requires billers to apply modifier GP with CPT code 97162 to distinguish physical therapy services from other therapies, such as speech-language pathology and occupational therapy.
Modifier 25
You may append modifier 25 to code 97162 if another evaluation and management (E/M) service was performed on the same day as the physical therapy evaluation. This modifier indicates that the two evaluation services are distinct and separately reimbursable.
CPT Code 97162 – Billing & Reimbursement Guidelines
You must carefully read the following billing and reimbursement guidelines for CPT code 97162, because a minor mistake can lead to claim denials.
Ensure the Correct Use of the Code
You must fulfill the criteria of CPT code 97162 to ensure its correct use. The criteria depend on three components: patient history, body systems examination, and clinical presentation.
Patient’s History
The historical context introduces an issue involving 1-2 individual factors and/or coexisting conditions that influence the care plan.
Body Examination
Three or more components from any of the following categories: bodily structures and functions, limitations in activities, or restrictions on participation.
Clinical Presentation
Moderate difficulty is observed when using standardized tools for patient evaluations or when conducting a quantifiable assessment of functional capabilities.
If your moderate complexity service does not qualify for any of the above-mentioned criteria, you must bill your evaluation using the lower code, 97161. Therefore, it is essential to be familiar with the details of this code.
Include Detailed Documentation
To qualify for accurate reimbursement, you must clearly communicate via your paperwork. Accurate documentation supports the necessity of the procedure and the use of CPT Code 97162. Your detailed documentation must ensure that the patient’s record, history, examination results, and clinical presentation meet the moderate complexity criteria. Sometimes, payers miss providing essential information. So, we recommend being vigilant and double-checking the paperwork to ensure it justifies the moderate complexity classification.
Check Payer Guidelines
Apart from Medicare and Medicaid, there are various other private insurance payers in the U.S. These payers have their unique policies for the billing of CPT code 97162. These policies may include specific documentation requirements, frequency limits on the service, and rules for appending modifiers.
So, therapists or their assigned billers should review these policies and confirm the payment rates from respective payers.
Final Word
In conclusion, CPT code 97162 represents a physical therapy evaluation of moderate complexity. The session lasts 30 minutes and must include an in-depth analysis of the patient’s medical history, a review of the body’s systems, and a review of the current clinical situation. However, to successfully secure your payment for this code, you must provide adequate documentation and append the appropriate modifiers.
However, if you are still struggling to bill physical therapy evaluations, consider hiring professional physical therapy billing services from specialists like MediBillMD.
