CPT 97161, cpt code 97161, 97161 cpt code

CPT 97161 | Description, Procedure & Billing Guidelines (2022)

CPT code 97161 may be used for physical therapy evaluation of low-complexity decision-making.

1. What Is CPT Code 97161?

CPT 97161 covers a procedure that is normally provided by a physical therapist (PT). They conduct physical therapy evaluation of low complexity decision making, which includes;

  1. The assessment of 1 or 2 elements that relate to the function and structure of the patient’s body, such as;
    • neuromuscular function;
    • mobility;
    • gait;
    • muscle strength; or
    • joint flexibility;
  2. The observation of the usability and complication of the patient’s status; and
  3. A check of the patient’s history for anything that could affect care.

The CPT code 97161 procedure is performed with standardized measures and tests. As a result, the provider uses clinical decisions of low complexity. 

The procedure normally takes about 20 minutes and is performed face-to-face with the patient or with the patient and the family.

2. Description

The CPT book defines CPT code 97161 as follows: “Physical therapy evaluation: low complexity, requiring these components:

  • A history with no personal factors and/or comorbidities that impact the plan of care;
  • An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
  • A clinical presentation with stable and/or uncomplicated characteristics; and
  • Clinical decision-making of low complexity using standardized patient assessment instruments and/or measurable assessment of functional outcomes.

Typically, 20 minutes are spent face-to-face with the patient and/or family.”

3. Procedure

CPT code 97161 describes the following procedure. A Physical Therapist (also called a PT) starts with an overall of the patient.

The physical therapist (PT) takes the patient’s medical history and assesses it for factors or contraindications that might influence the care plan.

Then, the Physical Therapist (PT) starts with an analysis of the;

  • mobility;
  • gross neuromuscular status;
  • coordination;
  • balance;
  • flexibility; and
  • muscle strength.

If the patient has a prosthetic device, it will also be reviewed by the Physical Therapist.

The Physical Therapist uses standardized measurements and tests that experts accept and agree upon.

The CPT 97161 procedure is performed with low complexity clinical decision-making and is performed face-to-face with the patient. The family can also be present during the assessment.

This procedure takes about 20 minutes, and the Physical Therapist reports the findings in the evaluation sheet.

The patient and/or the family might discuss physical therapy intervention and the diagnosis.

4. Billing Guidelines

Report CPT code 97161 only if the clinical decision-making is of low complexity. You may use CPT 97162 for moderate complexity and CPT 97163 for high complexity.

Report CPT 97164 for re-evaluation of the established care plan.

4.1. Does CPT Code 97161 Need A Modifier?

Yes, CPT 97161 needs a modifier. CMS states that this procedure code needs to be accompanied by modifier GP.

4.2 What CPT Code was Replaced By CPT 97161?

CPT code 97161 replaced CPT 97001. This code was split up into three new codes. CPT 97161 for low complexity, CPT 97162 for moderate complexity, and CPT 97163 for high complexity.

5. Resources

CPT Professional 2022

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9933.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3654CP.pdf

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=53309

https://www.aapc.com/codes/coding-newsletters/my-orthopedic-coding-alert/treatment-spinal-stenosis-tx-often-involves-injections-pt-161476-article

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