How To Use CPT Code 97163

CPT 97163 refers to a high complexity physical therapy evaluation, which includes a detailed history, examination, and clinical decision-making process. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 97163.

1. What is CPT 97163?

CPT 97163 is a code used to describe a high complexity physical therapy evaluation. This evaluation involves a comprehensive history, examination of body systems, and clinical decision-making process. The code is used by medical professionals, such as physical therapists, to accurately document and bill for the services provided during the evaluation.

2. 97163 CPT code description

The official description of CPT code 97163 is: “Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family.”

3. Procedure

1. The physical therapist (PT) conducts a thorough medical history, focusing on three or more personal factors and/or comorbidities that may impact the plan of care.
2. The PT performs an examination of body systems using standardized tests and measures, addressing a total of four or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.
3. The PT assesses the patient’s clinical presentation, which should exhibit unstable and unpredictable characteristics.
4. Using clinical decision-making of high complexity, the PT employs standardized patient assessment instruments and/or measurable assessments of functional outcomes.
5. Typically, the PT spends 45 minutes of face-to-face time with the patient and/or family during the evaluation.

4. Qualifying circumstances

Patients eligible to receive CPT code 97163 services are those who require a high complexity physical therapy evaluation. This includes patients with a history of present problems with three or more personal factors and/or comorbidities that impact the plan of care, an examination addressing four or more elements, a clinical presentation with unstable and unpredictable characteristics, and clinical decision-making of high complexity.

5. When to use CPT code 97163

It is appropriate to bill the 97163 CPT code when a physical therapist performs a high complexity physical therapy evaluation. This evaluation should include a detailed history, examination, and clinical decision-making process as outlined in the official description of CPT 97163. The code should be used to accurately document and bill for the services provided during the evaluation.

6. Documentation requirements

To support a claim for CPT 97163, the following information should be documented:

• A comprehensive medical history, including three or more personal factors and/or comorbidities that impact the plan of care.
• An examination of body systems using standardized tests and measures, addressing a total of four or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.
• A clinical presentation with unstable and unpredictable characteristics.
• Clinical decision-making of high complexity using standardized patient assessment instruments and/or measurable assessments of functional outcomes.
• Face-to-face time spent with the patient and/or family, typically 45 minutes.

7. Billing guidelines

When billing for CPT code 97163, it is essential to follow the appropriate guidelines and rules. Ensure that the documentation supports the high complexity of the evaluation and that all required components are included. Additionally, be aware of any specific payer requirements or policies related to billing for physical therapy evaluations. For physical therapy evaluations of low and moderate complexity, refer to CPT codes 97161 and 97162. For the re-evaluation of an established plan of care, see CPT code 97164.

8. Historical information

CPT 97163 was added to the Current Procedural Terminology system on January 1, 2017. There have been no updates to the code since its addition.

9. Similar codes to CPT 97163

Five similar codes to CPT 97163 include:

1. CPT 97161: Physical therapy evaluation of low complexity.
2. CPT 97162: Physical therapy evaluation of moderate complexity.
3. CPT 97164: Physical therapy re-evaluation of an established plan of care.
4. CPT 97165: Occupational therapy evaluation of low complexity.
5. CPT 97166: Occupational therapy evaluation of moderate complexity.

These codes differ from CPT 97163 in terms of the complexity of the evaluation, the number of personal factors and/or comorbidities, the number of elements addressed in the examination, and the level of clinical decision-making required.

10. Examples

Here are 10 detailed examples of CPT code 97163 procedures:

1. A patient with a history of stroke, diabetes, and hypertension requires a high complexity physical therapy evaluation to address mobility limitations, muscle weakness, and balance issues.
2. A patient with multiple sclerosis, depression, and a recent hip fracture requires a high complexity physical therapy evaluation to assess functional limitations, muscle strength, and coordination.
3. A patient with Parkinson’s disease, osteoarthritis, and a history of falls requires a high complexity physical therapy evaluation to address gait abnormalities, joint stiffness, and balance impairments.
4. A patient with a spinal cord injury, chronic pain, and obesity requires a high complexity physical therapy evaluation to assess mobility restrictions, muscle strength, and functional limitations.
5. A patient with a traumatic brain injury, cognitive impairments, and a recent lower extremity amputation requires a high complexity physical therapy evaluation to address prosthetic fitting, mobility limitations, and balance issues.
6. A patient with rheumatoid arthritis, fibromyalgia, and a history of joint replacements requires a high complexity physical therapy evaluation to assess joint mobility, muscle strength, and functional limitations.
7. A patient with a history of cancer, lymphedema, and neuropathy requires a high complexity physical therapy evaluation to address swelling, pain, and sensory impairments.
8. A patient with a complex regional pain syndrome, anxiety, and a history of multiple surgeries requires a high complexity physical therapy evaluation to assess pain levels, functional limitations, and coping strategies.
9. A patient with a history of Guillain-Barré syndrome, respiratory issues, and a recent hospitalization requires a high complexity physical therapy evaluation to address muscle weakness, endurance, and functional limitations.
10. A patient with a history of polio, scoliosis, and chronic pain requires a high complexity physical therapy evaluation to assess posture, muscle strength, and functional limitations.