Did the physical therapy evaluation you conducted involve highly complex decisions? You can bill it with CPT code 97163. With approximately 300 million annual therapy sessions, physiotherapists are highly valued in modern healthcare. In short, we know that you are an expert in diagnosing and treating injured or disabled people.
But are late payments impacting the quality and safety of your services? We can help you reduce your coding mistakes, including those in PT evaluations. Let’s take a closer look at the 97163 CPT code.
CPT Code 97163 Description
As you may have already gathered, CPT code 97163 is a part of the PT evaluation codes. But how does it differ from them? To be more specific, this code refers to a more comprehensive evaluation, involving the following key elements:
- The history of a patient with three or more personal factors that may impact the plan of care.
- Assessment of unstable or unpredictable clinical status
- Examination of four or more body systems, including structure, limitation, and function, via standardized tests
- High clinical complexity medical decision making (MDM)
In simple terms, physiotherapists use this code to report that they have spent at least 45 minutes examining a patient with several pre-existing problems and an unstable condition. The session includes face-to-face interaction with the patient (and his family, if they are present) and multiple standardized tests to develop a detailed care plan.
Scenarios Where CPT Code 97163 is Applicable
The key elements in the description have left you even more confused? Don’t worry as we have outlined the correct application of CPT code 97163 in the following scenarios:
Evaluating a PD Patient with Two Other Comorbidities
Approximately 90,000 people are diagnosed with Parkinson’s disease (PD) each year in the U.S. Physical therapy is one thing that keeps them on their toes, maintaining and even improving their symptoms.
So, for the first scenario of this code, suppose a 61-year-old man with this disease arrives at a physical therapy center. Upon evaluation, the physiotherapist also learns about his other two pre-existing conditions, hypertension and arthritis.
The healthcare provider conducts a detailed examination to analyze the patient’s facial muscle control, balance, gait, and muscle stiffness. Due to his unstable condition, the physiotherapist discusses the treatment plan with his family. She then uses CPT code 97163 to bill for this high complexity evaluation service.
Assessing a Child with Cerebral Palsy, Autism, and Epilepsy
Cerebral palsy is a common neurological disorder among children, affecting nearly 1 million people in the U.S. PT is often the key step in treating this condition. So, for this example, let’s assume a school-going child with this disorder experiences new movement issues. Therefore, his mother takes him to a physiotherapist.
Since cerebral palsy often coexists with autism, ADHD, and epilepsy, let’s also assume that the child has two of these comorbidities. As a result, the healthcare provider spends 45 minutes thoroughly examining the patient. She assesses his ability to perform several motor functions, like sitting, standing, rolling, and climbing.
Based on his unpredictable condition, she develops a changing treatment plan. Her billing team reports this high-complexity evaluation with CPT code 97163.
Post ACL-Surgery Evaluation
Although ACL tears are quite rare, impacting 1 in 3500 people in the U.S., they have long-term consequences. This includes the risk of developing arthritis. PT is usually one of the best rehabilitation options for this type of injury.
Therefore, for the final example of CPT code 97163, consider a professional skier who arrives at a physical therapy center for post-ACL surgery recovery. To develop a useful treatment plan, the healthcare provider conducts a detailed evaluation. During this session, the patient reveals he also has a history of depression and diabetes.
The physiotherapist then performs several tests to assess the athlete’s several body functions, including muscle stiffness and motion. He concludes that the patient’s condition is unstable and uses the 97163 code to bill for this service.
Applicable Modifiers for CPT Code 97163
You can apply the following modifiers to CPT code 97163:
Modifier GP
Was the evaluation part of an outpatient PT plan of care? Apply modifier GP to CPT code 97163. This is the most commonly used modifier with physical therapy codes.
Modifier 59
Did you conduct an evaluation on the same day as another therapy service? If the evaluation was distinct from that service, append modifier 59 to CPT code 97163.
CPT Code 97163 Billing & Reimbursement Guidelines
Similar evaluation codes confuse even the most seasoned coders. So, if you are hesitating because you are still not sure whether you are using the right PT assessment code, explore the following billing guidelines.
Verify Insurance Coverage
The first step before providing any service is to verify whether the patient’s insurance plan covers physical therapy. This proactive step will save you from a lot of headaches later.
Use CPT Code 97163 for High-Complexity PT Evaluation
As we emphasized in the description, this code is for a more comprehensive evaluation. Hence, avoid using this code if you have spent less than 45 minutes assessing a stable patient and have only made a simple decision. Still don’t understand how to determine an in-depth analysis? Pay attention to the next point.
Establish the Complexity of a PT Evaluation
The easiest way to choose an appropriate physical therapy evaluation code is to understand its criteria. For example, CPT code 97163 is only applicable when the analysis you conducted meets the following five conditions:
- Evaluating lasting for at least 45 minutes
- A patient with 3 or more simultaneously existing conditions (comorbidities) impacting the care plan.
- Comprehensive examination via standardized techniques to analyze a total of four or more body elements, including:
- Body Structures
- Functions
- Activity Limitations
- Participation Restrictions
- Unstable clinical presentation
- Very complex decision-making
Completely Document the Evaluation Session
The best way to justify the complexity of a physical therapy evaluation is to document the session thoroughly. This includes recording:
- The start and end time of the session
- Patient history, including underlying medical conditions
- Clinical justification (symptoms that are impacting a patient’s daily life)
- Tests you conducted to assess the patient’s body functions
- Findings
- Detailed care plan
Verify Payer Policies for PT
Lastly, you must maintain compliance with payer-specific policies. This includes keeping up with each insurance company’s coverage and billing requirements for physical therapy. Some payers may require you to use a specific modifier, like GP, while others may only reimburse PT after obtaining a pre-authorization.
Summary
Can you now determine the complexity of your PT evaluation? CPT code 97163 is a code for a comprehensive physical therapy evaluation. As we have mentioned this a number of times in our blog, this code is only applicable if the session involves high-level decision-making.
We have discussed what makes a PT assessment highly complex with a detailed description and three scenarios. So, use this code wisely. But if you are still confused due to this code’s key elements, you can always get a professional to code your services.
Our home health and family practice billing services cover all aspects of physical therapy. So, contact our team and experience accurate coding and quick processing.
