How To Use CPT Code 97164

CPT 97164 refers to the re-evaluation of a physical therapy established plan of care, requiring specific components and typically involving 20 minutes of face-to-face time with the patient and/or family. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 97164 procedures.

1. What is CPT 97164?

CPT 97164 is a medical billing code used to describe the re-evaluation of an established physical therapy plan of care. This code is utilized when a physical therapist conducts a re-evaluation that includes a review of the patient’s history, standardized tests and measures, and a revised plan of care using standardized patient assessment instruments and/or measurable assessment of functional outcomes. The procedure typically involves 20 minutes of face-to-face time with the patient and/or family.

2. 97164 CPT code description

The official description of CPT code 97164 is: “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 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.”

3. Procedure

1. The physical therapist reviews the patient’s medical history.
2. Standardized tests and measures are used to assess the patient’s body structure and function.
3. The physical therapist evaluates the patient’s progress and determines if any changes are needed in the plan of care.
4. A revised plan of care is developed using standardized patient assessment instruments and/or measurable assessment of functional outcomes.
5. The physical therapist spends approximately 20 minutes of face-to-face time with the patient and/or family to discuss the revised plan of care and any necessary adjustments.

4. Qualifying circumstances

Patients eligible to receive CPT code 97164 services are those who have an established physical therapy plan of care and require a re-evaluation due to changes in their condition, lack of progress, or the need for a revised plan of care. This may include patients who have experienced a significant change in their medical status, those who have not met their therapy goals, or those who require a modification in their treatment approach to achieve better outcomes.

5. When to use CPT code 97164

It is appropriate to bill the 97164 CPT code when a physical therapist conducts a re-evaluation of an established physical therapy plan of care, which includes a review of the patient’s history, standardized tests and measures, and a revised plan of care using standardized patient assessment instruments and/or measurable assessment of functional outcomes. This code should be used when the re-evaluation is necessary due to changes in the patient’s condition, lack of progress, or the need for a revised plan of care.

6. Documentation requirements

To support a claim for CPT 97164, the following information should be documented in the patient’s medical record:

• A detailed review of the patient’s medical history.
• Results of standardized tests and measures used to assess the patient’s body structure and function.
• A clear explanation of the need for a re-evaluation, including any changes in the patient’s condition or lack of progress.
• A revised plan of care using standardized patient assessment instruments and/or measurable assessment of functional outcomes.
• Documentation of the 20 minutes of face-to-face time spent with the patient and/or family discussing the revised plan of care and any necessary adjustments.

7. Billing guidelines

When billing for CPT code 97164, it is important to follow the appropriate guidelines and rules. Ensure that the re-evaluation is medically necessary and supported by the patient’s medical record. Additionally, be aware of any payer-specific requirements or policies related to billing for physical therapy re-evaluations. For initial physical therapy evaluations of low, moderate, and high complexity, refer to CPT codes 97161, 97162, and 97163, respectively.

8. Historical information

CPT 97164 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 97164

Five similar codes to CPT 97164 and how they differentiate are:

1. CPT 97161: Initial physical therapy evaluation of low complexity.
2. CPT 97162: Initial physical therapy evaluation of moderate complexity.
3. CPT 97163: Initial physical therapy evaluation of high complexity.
4. CPT 97165: Re-evaluation of occupational therapy established plan of care.
5. CPT 97166: Initial occupational therapy evaluation of low complexity.

10. Examples

Here are 10 detailed examples of CPT code 97164 procedures:

1. A patient with a history of low back pain requires a re-evaluation due to increased pain and decreased functional mobility.
2. A patient recovering from a stroke requires a re-evaluation to determine if their current plan of care is still appropriate based on their progress.
3. A patient with a recent total knee replacement requires a re-evaluation to assess their progress and determine if any changes are needed in their plan of care.
4. A patient with a chronic neurological condition requires a re-evaluation to assess their functional status and determine if any modifications are needed in their plan of care.
5. A patient with a history of shoulder pain requires a re-evaluation due to a lack of progress with their current plan of care.
6. A patient with a recent hip fracture requires a re-evaluation to assess their progress and determine if any changes are needed in their plan of care.
7. A patient with a history of neck pain requires a re-evaluation due to increased pain and decreased range of motion.
8. A patient recovering from a traumatic brain injury requires a re-evaluation to assess their cognitive and functional progress and determine if any changes are needed in their plan of care.
9. A patient with a chronic musculoskeletal condition requires a re-evaluation to assess their functional status and determine if any modifications are needed in their plan of care.
10. A patient with a history of ankle sprain requires a re-evaluation due to a lack of progress with their current plan of care.