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:

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!