Therapy Evaluation and Assessment Services

Therapy evaluation and assessment services involve clinical judgment and decision-making which is not within the scope of practice for therapy assistants. These services can only be provided by qualified clinicians i.e., a physician, non-physician practitioner (NPP), therapist or speech-language pathologist (SLP).

Therapy evaluation and re-evaluation codes can only be billed when the medical record supports a completed comprehensive evaluation. Documentation must support that the evaluative service was medically necessary based on the patient's current status and medical/functional history. Medicare does not reimburse for services related solely to workplace skills and activities. Additional evaluative services may be necessary when an episode of care is interrupted by a short-stay inpatient hospitalization or outpatient surgery that could reasonably impact the patient's therapy progression. Treatment codes should not be submitted for time spent providing evaluative services.

Initial Evaluations - (i.e., CPT ® 97161-97163, 97165-97167)
Providers may simultaneously receive multiple physician referrals for multiple medical conditions for one patient. When this occurs, it is expected that one qualified clinician from each appropriate discipline i.e., physical therapist (PT), and/or occupational therapist (OT), and/or SLP, will complete a thorough initial evaluation that encompasses each of the identified medical conditions. Following completion of the initial evaluation, other staff therapists specializing in specific medical conditions may treat the patient as needed. When medical necessity is supported, an initial evaluation is appropriate for:

  • A new patient who has not received prior therapy services.
  • A patient who has returned for additional therapy after having been discharged from prior therapy services for the same or for a different condition. Time spent evaluating this returning patient should not be coded as a re-evaluation. Prior discharge may have been due to one of the following:
    • Patient no longer significantly benefited from ongoing therapy services or;
    • Patient no longer required therapy services for an extended period of time or;
    • Patient experienced a significant change in medical status that necessitated discharge.
  • A patient who is currently receiving therapy services and develops a newly diagnosed unrelated condition. Example: A patient is currently receiving treatment following a total knee arthroplasty (TKA). During the therapy episode of care for the TKA, the patient develops an acute rotator cuff injury from an accident at home. The clinician determines that the rotator cuff injury is not related to the TKA. Therefore, it is reasonable for the clinician to provide and code for a new evaluation of the rotator cuff injury since it is a newly identified diagnosis for an unrelated condition.

For additional information, see the attached "Medical Necessity of Therapy Services" article in the Related Coverage Documents link below.

Re-Evaluations - (i.e., CPT ® 97164, 97168)
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.

Additional Assessments - (i.e., CPT ® 97750, 95831-95834, 95851-95852)
Assessment services are considered inclusive (not separately reimbursable) when they are provided on the same day as an initial evaluation or re-evaluation service. Routine assessments 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. Therapy assessment codes should only be billed when the medical record supports that formal tests and measurements were completed and that these additional non-routine assessment services were medically necessary based on the patient's current status and medical/functional history. Assessment services should not be billed using therapy treatment codes. Documentation must include a formal, date signed, distinctly identifiable findings report which includes:

  • Testing and/or measurement results with comparative values for specific standardized grading scales.
  • Provider's interpretation of results.
  • Support of how the findings were incorporated into the therapy plan of care, when applicable.

Sources

Coding Information

CPT Code Description
97161 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 instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.
97162 Physical therapy evaluation: moderate complexity, requiring these components:
  • A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;
  • An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following body structures and functions, activity limitations, and/or participation restrictions;
  • An evolving clinical presentation with changing characteristics; and
  • Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family.
97163 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.
97164 Reevaluation 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.
97165 Occupational therapy evaluation, low complexity, requiring these components:
  • An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem;
  • An assessment(s) that identifies 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation
97166 Occupational therapy evaluation, moderate complexity, requiring these components:
  • An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance;
  • An assessment(s) that identifies 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family.
97167 Occupational therapy evaluation, high complexity, requiring these components:
  • An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance;
  • An assessment(s) that identify 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • A clinical decision-making is of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family.
97168 Reevaluation of occupational therapy established plan of care, requiring these components:
  • An assessment of changes in patient functional or medical status with revised plan of care
  • An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and
  • A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family.

 

Revision History

Revision History Number Revision History Date Revision History Explanation
2 01/01/2017 This article is revised to change the initial PT/OT evaluation codes to 97162-97163 for PT and 97165-97167 for OT and Reevaluation codes to 97164 & 97168 and deleted CPT® codes 97001, 97002, 97003 & 97004 effective 01/01/2017. Also, this article now combines JFA A52760 into the JFB article A52773 so that both JFA and JFB contract numbers will have the same final MCD article number as JEB A52773.
1 10/01/2015 This article underwent format changes and grammatical revision.

 

Related Local Coverage Document Article

Medical Necessity of Therapy Services

 

Last Updated Dec 09 , 2023