CPT Codes for Physical Therapy Evaluations

Well here we are, six years into the great CPT code change of 2017 (as decreed by CMS and the AMA), which called for PTs to use a new set of evaluation and re-evaluation codes. Okay, that may have been a dramatic way to introduce that specific chapter in rehab therapy history, but with buzzwords like the Great Resignation, recession, and unprecedented times at play, I couldn’t help myself. 

By now, the not-so-new CPT codes have worked themselves into every EMR, and the terms low, moderate, and high complexity are no less common to rehab therapists than the 8-Minute Rule or reimbursement cuts. But, that does not make them any less confusing—particularly for the new therapists entering the scene! To help, here’s a handy explainer on CPT codes for physical therapy evaluations. 

PT Evaluation CPT Codes

Relegated to the windowless stacks library of the AMA, 97001 has been out of circulation for some time and replaced with a set of three different evaluative codes that are tiered according to patient complexity. Those codes are:

97161	Physical therapy evaluation: lowcomplexity
97162	Physical therapy evaluation: moderatecomplexity
97163	Physical therapy evaluation: highcomplexity

The APTA stated they hoped having three evaluation complexities would lead to improved payment reform from CMS, but six years in and there’s still no change. Presently, CMS maintains the work relative value unit (RVU) at 1.54 for all evaluation complexities, and re-evaluations are set at 0.96. In other words, CMS will reimburse the same amount for all three complexities—even if 97163 takes you more than 45 minutes to complete.

(For some background on how RVUs affect the dollar amount you see from Medicare reimbursements, check out this blog post created by our friend, Rick Gawenda. The APTA also has a downloadable calculator for you to check reimbursements by geography, as well.)

Levels of PT Evaluation Complexity

Now, the million-dollar question for any therapy professional is: how to classify the complexity of physical therapy evaluations? We’re glad you asked. To start, all the information needed will be collected in a thorough physical therapy evaluation. Here are the four main evaluation complexity factors collected in the PT evaluation, along with a few sub-factors:

1. Patient history
   1. Personal factors
      1. Patient age
      2. Education level
      3. Coping style
      4. Social background
      5. Lifestyle
      6. Character
      7. Attitudes
   2. Comorbidities
      1. Past medical history (examples below)
         1. Obesity
         2. Diabetes
         3. Hearing loss
         4. Visual deficits
         5. Cognitive deficits
2. Depth and results of examination and use of standardized tests and measures
   1. Expected progression
   2. Objective findings
3. Clinical presentation
   1. Status of current condition
   2. Mechanism of current condition
4. Clinical decision-making
   1. Goal establishment
   2. Prognosis and probable outcome
   3. Patient related outcome measures 

Vocabulary

Really quick, before we jump into the defining characteristics of each complexity level, let’s define a few terms that’ll pop up throughout this post:

• Body Regions: Refers to areas of the body, such as head, neck, back, lower extremities, upper extremities, and trunk.
• Body Systems: Includes the circulatory, skeletal, muscular, nervous, respiratory, immune, excretory, integumentary, lymphatic, cardiovascular, reproductive, and digestive systems.
• Body Structures: Refers to the body’s structural or anatomical parts (e.g., organs or limbs), which are classified according to body systems.
• Body Functions: Refers to physiological functions of body systems.

Now, let’s get into the nitty-gritty details associated with each level of evaluation complexity.

97161: Characteristics of a Low Complexity PT Evaluation

Duration	Typically, the PT spends 20 minutes face-to-face with the patient and/or family.
History	The patient has a history of the present problem without any personal factors and/or comorbidities that impact the plan of care.
Examination	The PT completes an examination ofbody system(s) using standardized testsand measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.
Clinical Presentation	The clinical presentation is stable and/or uncomplicated.
Decision-Making	The PT exercises clinical decision-making of low complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

97162: Characteristics of a Moderate Complexity PT Evaluation

Duration	Typically, the PT spends 30 minutes face-to-face with the patient and/or family.
History	The patient has a history of the present problem with a history of 1-2 personal factors and/or comorbidities that impact the plan of care.
Examination	The PT completes an examination of body systems using standardized tests and measures addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions.
Clinical Presentation	The clinical presentation is evolving with changing characteristics.
Decision-Making	The PT exercises clinical decision-making of a moderate complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

97163: Characteristics of a High Complexity PT Evaluation

Duration	Typically, the PT spends 45 minutes face-to-face with the patient and/or family.
History	The patient has a history of the present problem with 3 or more personal factors and/or comorbidities that impact the plan of care.
Examination	The PT completes 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.
Clinical Presentation	The clinical presentation is unstable with unpredictable characteristics.
Decision-Making	The PT exercises clinical decision-making of a high complexity, using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

PT Re-evaluation CPT Codes 

While I’m on the topic of PT evaluation codes, I’d be remiss to not mention 97164—the PT re-evaluation CPT code that replaced 97002 back in 2017. Luckily, there is no need to tier complexity when coding for a PT re-evaluation. This code is simply defined as: 

• Re-evaluation of physical therapy established plan of care requiring:
  • An examination (including a review of history and use of standardized tests and measures)
  • A revised plan of care (based on use of a standardized patient assessment instrument and/or measurable assessment of functional outcome)

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Hopefully this breakdown makes choosing the right level of complexity a little less, well, complex. Remember, clinical judgment plays a huge role in code selection, and your documentation should always clearly support your coding choices. That said, if you’re still scratching your head over the evaluation codes, leave us a question in the comment section below. We’ll do our best to track down an answer.

For more helpful billing FAQs, be sure to check out this blog post.