Current Procedural Terminology (CPT) codes are a standardized language used across healthcare to describe medical, surgical, and diagnostic services. Maintained by the American Medical Association (AMA), these codes are fundamental for accurate billing, processing insurance claims, and data analysis. For physical therapy, the initial evaluation is the foundational service, involving a comprehensive assessment of a patient’s physical status, functional limitations, and overall needs. The primary purpose of this assessment is to establish a diagnosis, determine a prognosis, and develop an individualized plan of care. Standardized coding ensures the complexity and scope of this service are consistently communicated to payers for proper reimbursement.
The Tiers of Initial Physical Therapy Evaluation Codes
Physical therapy evaluations are categorized into three specific CPT codes that reflect the varying levels of complexity encountered in patient care. This tiered system allows therapists to better document the resources and skill required for each initial assessment, based on the patient’s condition and the depth of the work performed.
The lowest level of service is CPT code 97161, corresponding to a low-complexity physical therapy evaluation. This code applies to patients whose clinical presentation is stable and uncomplicated, requiring a less extensive history and examination. Moving up, CPT code 97162 is used for a moderate-complexity evaluation, reserved for patients with more involved conditions, often involving changing characteristics that require deeper analysis.
The most involved assessment is CPT code 97163, identifying a high-complexity physical therapy evaluation. This code is appropriate for patients with unstable or unpredictable clinical presentations, necessitating an extensive history review and comprehensive examination. Code selection is based on documented requirements that define the complexity of the service provided, not on the time spent.
Determining the Complexity Level
The selection among the three initial evaluation codes is governed by four specific components defined by the AMA and Centers for Medicare & Medicaid Services (CMS). To justify a particular complexity level, documentation must meet the criteria for all four components at that level.
Patient History
This component assesses the personal factors and comorbidities that impact the plan of care. A low-complexity evaluation (97161) involves a history with no influencing factors or comorbidities. A high-complexity evaluation (97163) requires a history with three or more such factors.
Examination
The examination focuses on the number of elements addressed using standardized tests and measures, including body structures, activity limitations, and participation restrictions. A low-complexity exam (97161) addresses one or two elements. A moderate-complexity exam (97162) requires addressing three or more elements, and a high-complexity exam (97163) requires an assessment of four or more elements.
Clinical Presentation
This describes the stability and predictability of the patient’s symptoms and overall condition. A low-complexity case (97161) is stable and uncomplicated, following a typical course. A moderate-complexity case (97162) involves an evolving presentation with changing characteristics, such as fluctuating pain. The highest level (97163) is reserved for unstable and unpredictable characteristics, where the patient’s status may change suddenly.
Clinical Decision Making
This final component incorporates the analysis of collected data to establish a diagnosis and formulate a plan of care using a standardized assessment instrument or measurable functional outcome. The complexity of the decision-making process must align with the other three factors. A high-complexity evaluation (97163) involves a more intricate decision-making process due to the unstable nature of the patient’s condition.
Coding for Subsequent Assessments
Beyond the initial evaluation, physical therapists use CPT code 97164 for formal reassessment during the course of treatment. This re-evaluation code is designated for reassessing an established plan of care and should not be used for routine progress updates. A re-evaluation is medically necessary when a patient experiences a significant and unexpected change in status, such as a major decline or unanticipated improvement that fundamentally alters the existing plan.
The use of 97164 is also appropriate if the patient fails to respond as anticipated to therapeutic interventions, necessitating a comprehensive review and revision of goals. Documenting a re-evaluation requires a review of the patient’s history, an examination using standardized tests, and the development of a revised plan of care. This code ensures that the administrative work and clinical judgment involved in a formal reassessment are appropriately captured and billed.
When an evaluation or re-evaluation is performed on the same day as other therapeutic procedures, modifiers may be needed to ensure separate payment for distinct services. Modifier 59 is used to indicate that two services performed on the same day were separate and distinct. The therapist must ensure that the documentation clearly supports the medical necessity of the evaluation being distinct from any other service billed on the same date.