Master the frequency limitations, payer requirements, and common pitfalls when billing 97164 CPT code for physical therapy re-evaluations.
CPT Code 97164 is a physical therapy re-evaluation code used to bill for a formal reassessment of a patient who has previously received PT services. It is appropriate when there is a meaningful change in condition, function, risks, or goals that requires updating the plan of care—beyond routine progress monitoring.
Healthcare providers should know when to use 97164, how to document medical necessity, and what payer rules apply to ensure compliant reimbursement.
Understanding CPT 97164: Definition and Application
CPT Code 97164 represents a PT re-evaluation that reassesses the patient’s status, outcomes, goals, and plan of care. Typical face-to-face time is about 20 minutes, but time is descriptive and does not determine whether 97164 is appropriate; the clinical need and plan modification do.
The table below clarifies initial evaluation codes versus the re-evaluation code (typical times are guidance only):
| Code | Type | Complexity Level | Typical Duration* | When to Use |
| 97161 | Initial Evaluation | Low | ~20 minutes | Uncomplicated presentation; 1–2 exam elements; stable |
| 97162 | Initial Evaluation | Moderate | ~30 minutes | Evolving presentation; ≥3 exam elements; moderate complexity |
| 97163 | Initial Evaluation | High | ~45 minutes | Unstable/unpredictable presentation; ≥4 exam elements; high complexity |
| 97164 | Re-evaluation | N/A | ~20 minutes | Significant change in status or treatment response requiring POC update |
*Typical times are descriptive and do not drive code selection.
Clinical Situations That Require CPT 97164
Bill 97164 when a formal reassessment leads to meaningful plan changes. Examples:
| Clinical Trigger | Description | Documentation Required | Example Scenario |
| Significant Functional Change | Notable improvement or decline | Objective measures; updated function | Independent gait achieved after TKA; return-to-work capacity change |
| Lack of Expected Progress | Plateau or regression despite adherence | Barrier analysis; revised goals/interventions | No ROM gains after 4 weeks → alter approach |
| New Diagnosis/Condition | New issue affecting POC | Updated history; safety/precautions | New shoulder impingement during low back rehab |
| Post-Surgical Status Change | Precaution/status change or complication | Surgeon communication; new guidelines | Cleared for full weight-bearing after fracture healing |
| Equipment Needs Assessment | Device impacts mobility/ADLs | Trials; safety; functional testing | Wheelchair vs walker determination with training plan |
| Discharge Planning | End-of-episode decision-making | Outcomes; home/work demands | Final assessment before discharge or RTW decision |
Medical Necessity Requirements
To justify using cpt code 97164, documentation should show:
- Why re-evaluation is needed now (trigger/clinical change)
- What changed (objective data, outcomes, risks)
- How the plan will change (goals, frequency, interventions)
- Skilled rationale (why PT expertise is required for decisions/updates)
Documentation Standards and Billing Requirements
Use SOAP components aligned to medical necessity and clear plan updates.
Required SOAP Documentation Elements
| SOAP Component | Required Elements | Medicare/Commercial Considerations | Common Pitfalls |
| Subjective | Patient-reported changes; functional concerns; pain/symptom behavior | Include patient-specific goals and context | Vague “feels better/worse”; no functional detail |
| Objective | Repeat key tests/measures; outcomes; risk screens | Use standardized tools where appropriate | No numbers; subjective-only observations |
| Assessment | Clinical reasoning; response to care; barrier/risk analysis | Explicit rationale for re-eval and code | Generic statements; no link to plan changes |
| Plan | Updated goals (SMART), frequency/duration, interventions, precautions | Clearly state modifications to POC | Leaving plan unchanged after re-eval; no timeframes |
Payer-Specific Frequency Limitations
Frequency is payer- and plan-specific. Avoid blanket day-count rules; follow medical-necessity triggers and plan requirements.
| Payer Type | Frequency Limit | Timing Requirements | Special Considerations |
| Medicare | No fixed universal interval; event-driven | Demonstrate significant change and POC update | Physician/NPP POC certification and local MAC policies apply |
| Medicaid | State-specific | Check state guidance and MCO policies | Prior auth may be required for episodes/visits |
| Commercial Insurance | Plan-specific | Common review points at 30–90 days or visit thresholds | Verify plan documents; pre-auth/recert rules vary |
| Workers’ Compensation | Jurisdiction-specific | Based on case manager/UR review | Document work demands and safety |
Documentation Errors to Avoid
- Insufficient justification: No clear trigger or medical necessity for re-eval
- Missing objective data: Absent measurable findings or outcomes
- Unchanged plan: Re-eval billed but no updates to goals/interventions
- Timing violations: Re-evals too frequent without clinical cause or payer approval
- Incomplete SOAP: Missing components or generic language
When to Use CPT 97164: Clinical Decision-Making Guide
Choose 97164 when the clinical situation requires a formal reassessment with plan modifications; use a progress note when the patient is progressing as expected without changes to POC.
Clinical Scenarios and Appropriate Coding Decisions
| Patient Situation | Appropriate Code/Action | Rationale | Key Documentation Focus |
| Post-op patient cleared for full weight-bearing | CPT 97164 | Precaution change requires plan update | New restrictions/activities; revised goals and interventions |
| Plateau after 6 weeks of treatment | CPT 97164 | Lack of progress warrants reassessment | Barrier analysis; updated strategies; goal adjustments |
| New shoulder pain during back treatment | CPT 97164 | New condition affects overall approach | Expanded assessment; safety; integrated plan |
| Routine 2-week check with expected gains | Progress Note | Normal course; no POC change | Standard progress tracking; continue plan |
| Patient requests equipment evaluation | CPT 97164 | Device selection needs formal assessment | Trials; fit/safety; functional outcomes |
| Insurance authorization renewal | CPT 97164 (if plan requires) | Formal re-eval needed for coverage | Objective progress; medical necessity |
| Missed 3 weeks; uncertain status | Progress Note or 97164 | Depends on functional change | Screen for decline/improvement; decide accordingly |
| Discharge planning assessment | CPT 97164 | Comprehensive decision before discharge | Outcomes; safety; RTW/activity recommendations |
Provider Qualifications and Scope of Practice
A licensed physical therapist performs and bills 97164. PTAs may gather data as delegated but do not perform the re-evaluation or determine plan changes.
Billing CPT 97164 with Other Treatment Codes
97164 may be billed on the same day as treatment (e.g., therapeutic exercise) when the re-evaluation is medically necessary, separately identifiable, and properly documented. Follow payer bundling/modifier rules and ensure time/resources for treatment are not conflated with the re-eval.
Final Thoughts
CPT 97164 is essential for documenting meaningful changes in patient status and for aligning care with updated goals and risks. Use it when a clinical trigger necessitates formal reassessment and a revised plan of care—and show this clearly in SOAP with objective data and skilled rationale. Adhere to payer-specific rules, avoid generic language, and ensure each re-evaluation results in actionable plan updates that support safe, effective rehabilitation.
