PT/OT Re-Evaluations: CPT and Medicare Guidance on Coding

May 24, 2023
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Payment rates

Medicare pays for re-evaluations at a rate that is about 2X a timed treatment code. Commercial and work comp payment rates are generally in proportion to Medicare rates.

CPT Guidance on PT Re-Evaluation (97164)

CPT Definition of PT Re-Evaluation (97164)-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.

CPT Explanation (from AMA CPT Assistant)

Clinical Example (97164)

A 62-year-old male with low back pain presents for a physical therapy re-evaluation on his eighth visit of his episode of care. The patient had been making progress toward his goals. At his last visit, he reported a reduction in pain from 6/10 to 1/10 and an ability to return to driving and light exercise. However, at this visit, he presents with an increase in pain to 8/10 and describes radiation of pain and sensory loss in the right posterior leg and lateral foot. He is unable to sit for more than 3 minutes.

Description of Procedure (97164)

The updated patient medical history is reviewed, and current medications are confirmed. The patient’s self-reported and/or performance-based measurement outcome tool is reviewed. The examination during reevaluation includes measurement of gross range of motion as well as segmental mobility, neurologic status, and muscle strength. The patient’s and/or family/caregiver’s questions are answered as appropriate throughout the reevaluation. Interpretation of the patient’s response to tests and measures is recorded to assist with updating the plan of care.

CPT Guidance on OT Re-Evaluation (97168)

CPT Definition of OT Re-Evaluation (97168)-Re-evaluation 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.

CPT Explanation (from AMA CPT Assistant)

Code 97168 is used to report occupational therapy reevaluation that is based on an established and ongoing plan of care. This is in contrast to the evaluation codes that include development of a plan of care. The AOTA describes a re-evaluation as the “reappraisal of the patient’s performance and goals to determine the type and amount of change that has taken place.

Medicare and other third-party payers may have particular rules about when a re-evaluation may be reimbursed. The CPT code set guidelines only describe the components required to report the service. For example, the evaluations codes and the re-evaluation code describe typical time of 30 minutes for face-to-face interaction with the patient and/or family. Again, this is not to be considered a requirement or a limit on time.

Medicare Rules on PT/OT Re-Evaluations (from Medicare Benefit Policy Manual Ch 15, Section 220, 230)

  • Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a therapist indicates a significant improvement, or decline, or change in the patient’s condition or functional status that was not anticipated in the plan of care.
  • A re-evaluation should not be required before every progress report routinely but may be appropriate when assessment suggests changes not anticipated in the original plan of care.
  • Continuous assessment of the patient’s progress is a component of ongoing therapy services and is not payable as a re-evaluation.
  • Although some state regulations and state practice acts require re-evaluation at specific times, for Medicare payment, reevaluations must also meet Medicare coverage guidelines.
  • A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services.
  • Indications for a re-evaluation include new clinical findings, a significant change in the patient’s condition, or failure to respond to the therapeutic interventions outlined in the plan of care.
  • A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.
  • A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment or terminating services.
  • Only a therapist may perform an initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a plan of care. A therapist may include, as part of the evaluation or re-evaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the therapist must actively and personally participate in the evaluation or re-evaluation. The therapist may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.