Our prior focus in our blog, “The Misperception of a Physical Therapy Re-Evaluation (97002)” continues to be a very hot topic in the physical and occupational therapy industry. Since publishing that blog several years ago, the physical and occupational evaluation codes have changed. The edit specific to revaluations is that the original CPT code of 97002 (PT re-eval) has now been replaced with 97164 and the CPT Code of 97004 (OT re-eval) has been replaced with 97168.

In our experience, the most common question that we continue to receive from outpatient physical and occupational therapy providers is “When is it appropriate to bill the re-evaluation code for my services?”. To answer this question and provide clarity on this topic, we gathered some information directly from both CMS and Medicare Intermediaries.

When is it appropriate to bill the re-evaluation code 97164 (PT) or 97168 (OT)?

The following excerpt was published by Medicare Intermediary, Noridian, directly on their website.

Routine re-evaluations of expected progression in accordance with the plan of care, either during the episode of care or upon discharge, are not considered to be medically necessary separately billable services. When medical necessity is supported, a re-evaluation is appropriate for:

A patient who is currently receiving therapy services and develops a newly diagnosed related condition e.g., a patient that is currently receiving therapy treatment for TKA. During the episode of care, the patient develops wrist pain. The clinician determines that the wrist pain is due to use of a walker which the patient is using as a result of the TKA. In this scenario, the wrist pain is a condition that is related to the TKA. Therefore, it is reasonable for the clinician to provide a re-evaluation of the patient due to this related condition.
A patient who is currently receiving therapy services and demonstrates a significant improvement, decline, or change in condition or functional status which was not anticipated in the plan of care and necessitates additional evaluative services to maximize the patient’s rehabilitation potential.

Now let’s dig into this topic a bit more to answer some other commonly asked questions regarding the billing of a physical therapy re-evaluation code.

How much time should be spent on a re-evaluation?

The CMS Transmittal 3654 published on November 10, 2016 list the following information relevant to the re-evaluation code:

97164 – Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and a revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.

What modifiers should be used with the re-evaluation code?

The CMS Transmittal 1775 published on January 27, 2017 list the following information relevant to the re-evaluation code:

The new PT and OT codes are added to the current list of evaluative procedures that require a specific therapy modifier to identify the plan of care under which the services are delivered to be on the claim for therapy services. This payment policy requires that each new PT evaluative procedure code – 97161, 97162, 97163 or 97164 – to be accompanied by the GP modifier.

Is Functional Reporting required with the new re-evaluation code?

The CMS Transmittal 1775 published on January 27, 2017 list the following information relevant to the re-evaluation code:

In addition to other Functional Reporting requirements, current payment policy requires Functional Reporting, using G-codes and severity modifiers, when an evaluative procedure is furnished and billed. This notification adds the eight new codes for PT and OT evaluations and reevaluations – 97161, 97162, 97163, 97164, 97165, 97166, 97167, and 97168 – to the procedure code list of evaluative procedures that necessitate Functional Reporting. A severity modifier (CH – CN) is required to accompany each functional G-code (G8978-G8999, G9158-9176, and G9186) on the same line of service.

Can the new re-evaluation code be billed on the same day as other therapeutic procedures?

For the re-evaluation code, CMS bundles the 97164 with all the other 97000 series codes. This does not restrict a therapist from performing a re-evaluation on the same day as another therapeutic procedure, but does require an additional modifier -59 on the claim to indicate to Medicare that the procedures were separate and distinct services. Additionally, the therapist must be sure to document that both services were distinctly separate and medically necessary.

With payer rules and regulations constantly changing, it is important to make sure that your physical therapy billing company is not only staying up to speed with these changes, but just as importantly, doing everything in their power to make these changes as seamless as possible for your practice. Each physical therapy billing company is unique in the way they operate internally and service their customers. To learn more about how StrataPT has been able to help other outpatient physical therapy owners grow their business, check out our video below:

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The Misperception of a Physical Therapy Re-Evaluation – Part II