Over the years, we've received a lot of questions about when to bill for an evaluation versus a re-evaluation, and when you look at the description for CPT code 97164 (PT Re-evaluation), it's easy to see why. According to the American Medical Association, 97164 denotes a re-evaluation of an established plan of care, which requires these components:

  • “an examination including a review of history and use of standardized tests and measures;”
  • “a revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome;” and
  • typically, 20 minutes face-to-face with the patient and/or family.

That's a lot of words, but it doesn't tell you much—particularly, when it's appropriate to bill for a re-evaluation instead of an initial eval. So, to clear up some confusion, we put together a few common situations in which a physical therapist must choose between billing for an initial eval and a re-eval—along with our advice on how to handle those situations:

The PT’s Guide to Billing - Regular BannerThe PT’s Guide to Billing - Small Banner

A current patient develops a newly diagnosed, related condition.

Use: Re-evaluation (97164)

If you are treating a patient, and he or she presents with a second diagnosis that is either related to the original diagnosis or is a complication resulting from the original diagnosis, you'll need to complete a re-evaluation and create an updated plan of care.

Example: A 15-year-old high school soccer player has an original plan of care for right patellofemoral pain syndrome, and she obtains a second referral for similar symptoms in the left knee.

A current patient develops a newly diagnosed, unrelated condition.

Use: Initial Evaluation (97161–97163)

Conversely, when a patient with an active plan of care presents with a second condition that is totally unrelated to the primary issue, you should select the appropriate initial evaluation code. The nuance for therapists to remember is that a re-evaluation is triggered by a significant clinical change in the condition for which the original plan of care was established. The second, unrelated problem (i.e., with a different body part or body system) may not, in and of itself, result in a change to the original condition.

Example: A 15-year-old high school soccer player has an original plan of care for right patellofemoral pain syndrome, and she obtains a second referral for upper back pain related to scoliosis.

A patient undergoing therapy treatment demonstrates an unexpected and significant change in status.

Use: Re-evaluation (97164)

This could include any improvement, decline, or other change in functional status that:

  1. you didn't anticipate when you originally established the plan of care, and
  2. requires further evaluation to ensure the best therapy outcomes.

Example: You're treating a 39-year-old hairstylist for right rotator cuff impingement, but you notice a severe decline in the range of motion that you did not anticipate when you established the original treatment plan. In this instance, you would need to further evaluate the patient to understand the root cause of the decline.

A patient does not respond as anticipated to the treatment outlined in the current plan of care, and a change to the plan is necessary.

Use: Re-evaluation (97164)

If, during the course of care, you determine that the original plan isn't having the intended effect on the patient, you may feel it necessary to change the plan of care. In this case, you would perform—and bill for—a re-evaluation.

Example: An 82-year-old retired school teacher has an original plan of care for bilateral knee osteoarthritis, and his or her function does not improve within the established plan of care timeline.

A patient undergoes surgery mid-plan of care.

Use: Re-evaluation (97164)

Re-evaluations also may be appropriate for patients who received therapy treatment prior to surgery and then returned for additional rehabilitation after surgery. The catch in this situation is that some commercial payers may consider the post-optreatment period a new episode of care, in which case you'd need to use an evaluation code.

Example: You treat a patient for osteoarthritis. The patient then undergoes a total knee arthroplasty, followed by more therapy.

A former patient returns to therapy after discharge with complaints similar to those you treated previously.

Use: Initial Evaluation (97161–97163)

Unfortunately, there isn't a whole lot of solid guidance on this scenario. However, in the case of Medicare, if 60 days have passed, you must start the case over with an initial evaluation. That's because Medicare automatically discharges a case when no claims have been submitted for 60 days. But again, this rule specifically applies to Medicare. For those patients with commercial insurances, you should defer to the payer—as well as your state practice act if it includes guidance on when evaluations and re-evaluations are appropriate.

Example: You treat a 30-year-old carpenter for right rotator cuff weakness and discharge him or her from care. Six months later, he or she returns with similar complaints.


So, there you have it: a general guide to determining when to bill for an initial eval versus a re-evaluation. Hopefully, these scenarios help you determine the best course of action the next time you're faced with this choice. But if you have any questions, let us know in the comment section below!

  • The 8-Minute Rule Showdown: Medicare vs. AMA Image

    articleNov 25, 2015 | 5 min. read

    The 8-Minute Rule Showdown: Medicare vs. AMA

    The guidelines for using the 8-Minute Rule are kind of like the instructions for building a piece of furniture from IKEA: they appear simple at first, but before you know it, you’ve been struggling for hours, you’ve got a lopsided futon, and there are seven leftover screws of various shapes and sizes scattered around your living room floor (maybe they’re just extras, right?). To make matters even more confusing, not all payers adhere to the same set …

  • 6 Biggest Factors Impacting Your PT Clinic’s Cash Flow Image

    articleJul 23, 2018 | 8 min. read

    6 Biggest Factors Impacting Your PT Clinic’s Cash Flow

    Most of us went into physical therapy so we could make a difference in our patients’ lives. PT can be extremely fulfilling and rewarding—and for many of us, owning a practice has been a lifelong dream. Once that dream becomes a reality, however, it can be a sobering experience. Bills need to be paid and bottom lines need to be met. It’s not always easy to bring in enough money to cover cancellations and billing snafus, not …

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.) Questions …

  • Common Questions from Our Medicare Open Forum Webinar Image

    articleOct 25, 2018 | 43 min. read

    Common Questions from Our Medicare Open Forum Webinar

    Earlier this week, WebPT President Dr. Heidi Jannenga, PT, DPT, ATC, teamed up with Rick Gawenda, PT—President and CEO of Gawenda Seminars & Consulting—to host a Medicare Open Forum . As expected, we received more questions than our Medicare experts could answer during the live session, so we've provided the answers to the most frequently asked ones below. Don't see the answer you're looking for? Post your question in the comment section at the end of this …

  • Maintenance, Medicare, and Medical Necessity: Unpacking the Jimmo Update Image

    articleOct 5, 2017 | 5 min. read

    Maintenance, Medicare, and Medical Necessity: Unpacking the Jimmo Update

    Hey, have you heard the good news? CMS has completed all required action items laid out in the Jimmo v. Sebelius settlement. If you’re scratching your head and wondering why that matters, here’s the rundown: a few years ago, a group of Medicare providers alleged that CMS contractors made determinations on claims for skilled care based on an inappropriate “Improvement Standard.” These providers took CMS to court, and the court determined that CMS needed to clarify and …

  • Common Questions from Our PT Billing Open Forum Image

    articleAug 18, 2018 | 34 min. read

    Common Questions from Our PT Billing Open Forum

    Last week, WebPT’s trio of billing experts—Dr. Heidi Jannenga, PT, DPT, ATC/L, WebPT President and Co-founder; John Wallace, PT, MS, WebPT Chief Business Development Officer of Revenue Cycle Management; and Dianne Jewell, PT, DPT, PhD, WebPT Director of Clinical Practice, Outcomes, and Education—hosted a live open forum on physical therapy billing . Before the webinar, we challenged registrants to serve up their trickiest PT billing head-scratchers—and boy, did they deliver! We received literally hundreds of questions on …

  • Founder Letter: 97002 and 97004 (Re-Evaluation) Myths Debunked Image

    articleJun 3, 2014 | 4 min. read

    Founder Letter: 97002 and 97004 (Re-Evaluation) Myths Debunked

    Let’s start off with a hypothetical example: You’re working with a Medicare patient. It’s the tenth visit and you need to conduct a routine reassessment, so you complete a progress note. Your boss then asks why you didn’t bill for a re-evaluation. Should you have? This scenario happens daily. If it’s not your boss questioning you, then maybe it’s yourself asking, “Should I bill a re-evaluation code for the time spent completing my reassessment of this patient?” …

  • Counting the Clock: 7 Must-Know Facts about Billable PT Treatment Time Image

    articleJul 8, 2015 | 7 min. read

    Counting the Clock: 7 Must-Know Facts about Billable PT Treatment Time

    In the classic 1993 legal flick The Firm, Gene Hackman’s veteran attorney character advises a rookie associate (played by a young and dashingly handsome Tom Cruise) to bill for any hours he spends “even thinking about a client”—whether he’s “stuck in traffic or shaving or sitting on a park bench.” Unfortunately, the rules governing billable time in rehab therapy are not as, shall we say, open to interpretation. In fact, billing for every single minute of a …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.