CPT Code 97164 A Guide for PT Billing Success
Accurate billing is the backbone of a profitable physical therapy practice, and CPT code 97164 plays a pivotal role in documenting re-evaluations. However, confusion around its application, reimbursement, and how it differs from codes like 97110 (therapeutic exercise) or 97016 (manual therapy) can lead to costly errors.
This guide breaks down everything you need to know about CPT code 97164 to ensure compliance, clarity, and optimal revenue.
What Is CPT Code 97164?
CPT code 97164 refers to a re-evaluation of a physical therapy treatment plan. Unlike initial evaluations (coded under 97161-97163), 97164 is used when a therapist reassesses a patient’s progress, adjusts functional goals, or modifies interventions. This code represents 15 minutes of skilled clinical time and requires thorough documentation of:
- Changes in the patient’s condition.
- Updates to the treatment plan.
- Clinical reasoning for adjustments.
This code is critical for demonstrating medical necessity to payers and ensuring continuity of care.
Key Differences between 97164 and Other Physical Therapy CPT Codes
Understanding how 97164 compares to common codes like 97110, 97016, or 97116 (gait training) prevents coding overlaps and denials:
- 97164 (Re-Evaluation): Focuses on reassessment and plan updates. Not for hands-on treatment.
- 97110 (Therapeutic Exercise): Targets strength, flexibility, or endurance through guided exercises.
- 97016 (Manual Therapy): Covers hands-on techniques like joint mobilization or soft tissue work.
- 97116 (Gait Training): Addresses walking mechanics and mobility rehabilitation.
Pro Tip: Use 97164 only when no other treatment is provided during the session. If combining re-evaluation with therapy (e.g., 97110), append modifier GP (physical therapy) or 59 (distinct service) to justify separate billing.
When to Use CPT Code 97164 (And When Not To)
Appropriate Scenarios:
- Monthly progress reviews.
- Post-hospitalization reassessments.
- Significant changes in patient status (e.g., new pain, plateaued progress).
Avoid These Mistakes:
- Billing 97164 for initial evaluations (use 97161-97163 instead).
- Using it for routine treatment sessions without a formal re-evaluation.
Failing to document time spent analyzing data or updating plans
CPT Code 97164 Reimbursement and Modifiers
- Reimbursement Rates
Medicare typically reimburses 97164 between 25–25–40, while private insurers may pay higher rates. To avoid denials:
- Link re-evaluations to measurable functional goals (e.g., “Patient regained 50% shoulder ROM”).
- Highlight medical necessity in notes (e.g., “Plan modified due to persistent edema”).
Modifiers
- Modifier GP: Clarifies the service as physical therapy.
- Modifier 59: Use if 97164 is billed alongside another code (e.g., 97016) on the same day.
- Modifier KX: Ads proof of medical necessity for Medicare claims.
Example: A 30-minute session with 15 minutes of re-evaluation (97164-GP) and 15 minutes of manual therapy (97016-GP) may require modifier 59 to prevent bundling.
Time Requirements for CPT Code 97164
This code represents 15 minutes of skilled time, which includes:
- Patient interaction (e.g., assessing pain levels).
- Reviewing progress data.
- Updating the treatment plan.
Note: Time spent on administrative tasks (e.g., writing notes) doesn’t count toward the 15-minute threshold.
3 Strategies to Maximize Reimbursement
- Document Rigorously: Include timestamps, clinical rationale, and updated goals.
- Pair with Time-Based Codes: Bill 97164 alongside codes like 97110 if services are distinct.
- Audit Payer Policies: Some insurers cap re-evaluations (e.g., once every 30 days).
Common Pitfalls and How to Avoid Them
- Under coding: Skipping 97164 to avoid audits risks lost revenue.
- Overlapping Services: Medical Billing 97164 with similar codes without modifiers.
- Vague Notes: Phrases like “patient improved” lack specificity. Instead, write, “Patient ascended 12 stairs independently, up from 5.”
Why CPT Code 97164 Matters for Your Practice
Re-evaluations aren’t just a billing requirement—they’re a clinical necessity. Proper use of 97164 ensures:
- Compliance with payer guidelines.
- Transparent communication with insurers.
- Improved patient outcomes through adaptive care.
