Physical Therapists’ Guide to CPT Codes

Created and maintained by the American Medical Association, the Current Procedural Terminology (CPT) code set accounts for medical, surgical, and diagnostic services.

Like ICD codes, CPT codes communicate uniform information about medical services and procedures to healthcare payers. The difference is that on claim forms, CPT codes identify services rendered rather than patient diagnoses.

What are the most common physical therapy CPT codes?

Below are the most common CPT codes recorded within WebPT:

97110 Therapeutic Exercise
97140 Manual Therapy
97112 Neuromuscular Re-Education
97530 Therapeutic Activities
97010 Hot/Cold Packs
97014 Electrical Stimulation (Unattended)
G0283 Electrical Stimulation, Medicare Non-Wound (Unattended)
97035 Ultrasound/Phonophoresis
97161 PT Evaluation: Low Complexity
97116 Gait Training
97162 PT Evaluation: Moderate Complexity
97535 Self Care/Home Management Training
97016 Vasopneumatic Device
97032 Electrical Stimulation (Manual)
97012 Mechanical Traction
97164 PT Re-Evaluation
97113 Aquatic Exercise
97150 Group Therapy
97124 Massage
97018 Paraffin Bath
NC001 No Charges This Visit
97163 PT Evaluation: High Complexity
98941 Spinal, Three or Four Regions
97022 Whirlpool
97033 Iontophoresis
98940 Chiropractic Manipulative Treatment (CMT); Spinal, One or Two Regions
97039 Laser/Other
97026 Infrared Light
97750 FCE/Performance Test
98943 CMT, Extraspinal, One or More Regions

CPT codes are copyright 1995-2019 American Medical Association. All rights reserved.

What’s the difference between ICD-10 and CPT codes?

As mentioned in the intro above, while CPT codes are similar to ICD-10 codes in that they both communicate uniform information about medical services and procedures, CPT codes identify services rendered rather than diagnoses. In short, CPT codes are procedure codes and ICD-10 codes are patient diagnosis codes.

Here is an example of ICD-10 and CPT codes in use: today, if you diagnose a patient with “Benign paroxysmal vertigo, bilateral,” you would use the ICD-10 code H81.13 to indicate your diagnosis. Then, you might complete standard canalith repositioning on your patient, in which case you would include CPT procedural code 95992 on your claim.

What is modifier 59? How do I use it?

Update: Beginning July 1, 2019, CMS will unbundle NCCI edit pairs when providers attach the appropriate modifier (59, XE, XS, XP, or XU) to either the first-column or second-column code (assuming, of course, that the situation warrants the use of one of these modifiers). Please note that while some Medicaid programs, commercial payers, and Medicare Advantage payers may follow suit, this change does not necessarily affect them, so be sure to reach out to your other payers to determine where they stand. Learn more here.

The CPT Manual defines modifier 59 as the following:

“Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures [and/or] services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”

That explanation is a bit dense, and it’s not super relatable. But that’s because modifier 59 is intended mainly for surgical procedures, so the definition leans a great deal that way.

So, how does modifier 59 come into play in the therapy setting? If you’re providing two wholly separate and distinct services during the same treatment period, it might be modifier 59 time. The National Correct Coding Initiative (NCCI) has identified procedures that therapists commonly perform together and labeled these “edit pairs.” Thus, if you bill a CPT code that is linked to one of these pairs, you’ll receive payment for only one of the codes. It’s therefore your responsibility as the therapist to determine whether you’re providing linked services or wholly separate services. This, in turn, determines whether modifier 59 is appropriate.

Modifier 59 Example

For example, let’s look at one of the most commonly billed codes: 97140 (manual therapy techniques like mobilization/manipulation, manual lymphatic drainage, or manual traction on one or more regions, each for 15 minutes). According to NCCI, the following are considered linked services when billed in combination with 97140: 95851, 95852, 97164, 97168, 97018, 97124, 97530, 97750, and 99186. So, if you bill any of these codes with 97140, you’ll receive payment for only 97140. Medicare actually uses this example on its site to explain appropriate use of modifier 59 among rehab therapists.

CMS states that when billing 97140 and 97530 (therapeutic activities; direct, one-on-one patient contact by the provider; or use of dynamic activities to improve functional performance, each for 15 minutes) for the same session or date, modifier 59 is only appropriate if the therapist performs the two procedures in distinctly different 15-minute intervals. This means that you cannot report the two codes together if you performed them during the same 15-minute time interval.

If the care you provide meets the appropriate criteria, you can add modifier 59 to 97530 to indicate it was a separate service and should be payable in addition to the 97140. The same holds true for billing 97140 with 95851, 95852, 97164, 97168, 97018, 97530, or 97750. However, you can never bill 97124 with 97140—and you cannot add any modifier to change this restriction, because these codes are mutually exclusive procedures, according to CMS.

When should I use modifier 59?

Modifier 59 can monumentally impact your Medicare reimbursements, and unfortunately, it’s the modifier physical therapists struggle with most. Perhaps that’s because the CPT Manual doesn’t offer the most helpful guidance. Therefore, we recommend asking the following questions to decide if and when you should use modifier 59.

Are you billing for two services that form an NCCI edit pair?

There are instances in which it’s appropriate to use modifier 59 in conjunction with physical therapy services. Recognizing those instances, though, requires you to recognize NCCI edit pairs. To make a long story short, edit pairs—also called linked services—are sets of procedures that therapists commonly perform together. If you submit a claim containing both of the codes in an edit pair, you’ll only receive payment for one of the procedures, because the payer will assume that one of the services was essentially “built into” the other.

Did you perform those two services separately and independently of one another?

Okay, so you’re dealing with an edit pair. But what if—for whatever reason—you actually didn’t perform those services together? That’s where modifier 59 comes into the picture. Basically, when you append modifier 59 to one of the CPT codes in an edit pair, it signals to the payer that you provided both services in the pair separately and independently of one another—meaning that you also should receive separate payment for each procedure.

Does your documentation support your assertion that you performed the two services separately and independently of one another?

When it comes to telling your patients’ stories, codes and modifiers can only say so much. It’s on you to fill in the plot holes with detailed, defensible documentation. After all, your documentation justifies your billing decisions—and if you’re ever faced with an audit, your notes will be your main source of proof that those decisions were the right ones. That means you should never:

  • append modifier 59 simply because you know it will guarantee payment.
  • skimp on your documentation—or intentionally document vaguely or misleadingly.
  • routinely use the 59 modifier in conjunction with re-evaluation codes. (Doing so could throw up a red flag to your payers.)

Let’s assume that, yes, your documentation does support your assertion that you performed the two services separately and independently of one another. So, next you’d ask:

Is a more descriptive modifier available?

Clinicians, coders, and billers should only use modifier 59 as a last resort (i.e., when there’s not a better option). As the CPT Manual states, “…when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”

Now, you’ve probably heard talk about the new set of modifiers that CMS created for providers to use in place of modifier 59, when appropriate. The new modifiers—XE, XP, XS, and XU—are intended to bypass a CCI edit by denoting a distinct encounter, anatomical structure, practitioner, or unusual service. However, even though these modifiers went into effect January 1, 2015, the APTA has stated that therapists do not need to start using them in place of modifier 59—at least not yet. That being said, therapists may be required to use the new modifiers in the future, so keep an eye—or an ear—out for further instruction regarding modifier 59 usage.

Download your modifier 59 decision chart.

Enter your email address below, and we’ll send you a super-simple flow chart to help you decide whether it’s appropriate to use modifier 59 in any given billing situation.

What are the most commonly used CCI edits for PT, OT, and SLP private practice settings?

Below is a table with the most common CCI edit pairs related to different therapy types, courtesy of PT compliance expert Rick Gawenda, owner of Gawenda Seminars & Consulting. Here’s how to use the chart:

  1. Look for the primary CPT code you are billing in Column 1.
  2. Check Column 2. If you are billing any of the codes listed, they will be considered mutually exclusive or linked.
    1. If the code in Column 2 has a “y” next to it, you can add modifier 59.
    2. If there’s an “n,” then you should not bill the code in combination with the code in Column 1.

Please note that this is not the complete list of NCCI edits for the CPT codes listed; you can find the complete list on CMS’s website here. Most government payers—like Medicare, Tricare, and Medicaid—use this same list. However, private payers often create their own edit pairs; therefore, there is no guarantee they will pay, even with an applied modifier 59. Codes that are formatted in bold denote new NCCI edits (as of April 2019).

Download your CCI Edit Chart.

Want the below table in a printable, easy-to-reference PDF? Enter your email address, and we’ll send it your way.

Version 25.1 Correct Coding Initiative (CCI) Edits

Current as of April 2019

CPT Code Description Timed? Column 2
y = use 59 modifier
n = do not bill the code in combination with code in column 1
90911 Biofeedback for Incontinence N 90901n; 97032y; 97110y; 97112y; 97530y; 97535y; 97550y
G0451 Developmental Testing N 96125y; 96127n; 96146y; 96160y; 96161y
92507 Treatment of Speech and Language, Individual N 0373Tn; 36591n; 36592n; 69209n; 69210n; 96523n; 97110y; 97112y; 97127y; 97150y; 97153n; 97154n; 97155n; 97156n; 97157n; 97530y; 97532y; 97533y; G0515y
92508 Speech Group N 36591n; 36592n; 69209n; 69210n; 92507y; 96523n; 97110y; 97112y; 97127y; 97150y; 97154n; 97155n; 97156n; 97157n; 97158n; 97530y; 97532y; 97533y; G0515y
92521 Evaluation of Speech Fluency N 36591n; 36592n; 69209n; 69210n; 92620n; 92621n; 96105y; 96125y; 96130y; 96132y; 96136y; 96138y; 96146y; 96523n; 97151y; 97152y; G0505y; G0268n
92522 Evaluation of Speech Production N 36591n; 36592n; 69209n; 69210n; 92620n; 92621n; 96105y; 96125y; 96130y; 96132y; 96136y; 96138y; 96146y; 96523n; 97151y; 97152y; G0505y; G0268n
92523 Evaluation of Speech Production with Evaluation of Language Comprehension and Expression N 36591n; 36592n; 69209n; 69210n; 92522n; 92620n; 92621n; 96105y; 96125y; 96130y; 96132y; 96136y; 96138y; 96146y; 96523n; 97151y; 97152y; G0505y; G0268n
92524 Behavioral and Qualitative Analysis of Voice and Resonance N 36591n; 36592n; 69209n; 69210n; 92620n; 92621n; 96105y; 96125y; 96130y; 96132y; 96136y; 96138y; 96146y; 96523n; 97151y; 97152y; G0505y; G0268n
92526 Treatment of Swallowing Dysfunction N 36591n; 36592n; 92511y; 92520y; 96523n; 97032n; 97110y; 97112y; 97127y; 97150y; 97530y; 97532y; G0270n; G0271n; G0283n; G0515y
92597 Evaluation of Voice Prosthetic N 36591n; 36592n; 96523n; 97755n
92607 Evaluation of Speech Generating Device (SGD); First Hour Y 36591n; 36592n; 92507y; 92508y; 92521y; 92522y; 92523y; 92524y; 92597n; 92609y; 96523n; 97755n
92608 Evaluation of Speech Device (Each Additional 30 Minutes) Y 36591n; 36592n; 96523n; 97755n
92609 Programming and Training for Speech Generating Device N 36591n; 36592n; 92507y; 92508y; 92521y; 92522y; 92523y; 92524y; 96523n; 97755n
92610 Evaluation of Swallowing N 35691n; 35692n; 92511y; 96523n
92611 Modified Swallow Study N 36591n; 36592n; 70370y; 70371n; 76120n; 76125n; 92511y; 92610y; 96523n
92612 Flexible Endoscopic Evaluation of Swallowing N 31575n; 36591n; 36592n; 76120n; 76125n; 92511n; 92520n; 92610y; 92611y; 92614n; 96523n
92614 Flexible Endoscopic Evaluation; Laryngeal Sensory Testing by Cine or Video Recording N 31575n; 36591n; 36592n; 76120n; 76125n; 92511n; 92520n; 92610y; 92611y; 96523n
92616 Flexible Endoscopic Evaluation of Swallowing and Laryngeal Sensory Testing by Cine or Video Recording N 31575n; 36591n; 36592n; 76120n; 76125n; 92511n; 92520n; 92610y; 92611y; 92612n; 92614n; 96523n
95831 Muscle Testing, Extremity (Excluding Hand) or Trunk N 36591n; 36592n; 95851n; 97140y
95832 Muscle Testing, Hand N 36591n; 36592n; 95852n; 97140y
95833 Muscle Testing, Total Eval Body, Excluding Hands N 36591n; 36592n; 95831n; 95832n; 95851n; 97140y
95834 Muscle Testing, Total Eval Body, Including Hands N 36591n; 36592n; 95831n; 95832n; 95833n; 95851n; 95852n; 97140y
95992 Canalith Repositioning N 36591n; 36592n; 92531n; 92532n; 97110y; 97112y; 97140y; 97530y
96105 Assessment of Aphasia Y 36591n; 36592n; 96110y; 96125y; 96127n; 96146n; 96160y; 96161y; 96523n; 97151n; 97152n; 97153n; 97154n; 97155n; 97156n; 97157n; 97158n; ; G0451y; G0505y
96110 Developmental Testing, Limited N 36591n; 36592n;; 96125y; 96146n; 96523n; 97151n; 97152n; 97153n; 97154n; 97155n; 97156n; 97157n; 97158n
96112 Developmental Test Administration; First Hour Y 0362Tn; 0373Tn; 36591n; 36592n; 90791y; 90792y; 90832y; 90833y; 90834y; 90836y; 90837y; 90838y; 90839y; 90845y; 90846y; 90847y; 90849y; 90853y; 90865y; 90870y; 90880y; 92002y; 92004y; 92012y; 92014y; 96105y; 96110n; 96125y; 96127n; 96130y; 96131y; 96132n; 96133n; 96136n; 96137n; 96138n; 96146n; 96160y; 96161y; 96523n; 97151n; 97152n; 97153n; 97154n; 97155n; 97156n; 97157n; 97158n; 97161y; 97162y; 97163y; 97164y; 97165y; 97166y; 97167y; 97168y; G0380y; G0381y; G0382y; G0383y; G0384y; G0406y; G0407y; G0408y; G0410y; G0411y; G0425y; G0426y; G0427y; G0451n; G0459n; G0463y; G0508y; G0509y; Check E&M Codes as well (99201 – 99497)
96113 Developmental Test Administration; Each Additional 30 Minutes Y 0362Tn; 0373Tn; 36591n; 36592n; 90791y; 90792y; 90832y; 90833y; 90834y; 90836y; 90837y; 90838y; 90839y; 90845y; 90846y; 90847y; 90849y; 90853y; 90865y; 90870y; 90880y; 92002y; 92004y; 92012y; 92014y; 96110n; 96125y; 96127n; 96146n; 96160y; 96161y; 96523n; 97151n; 97152n; 97153n; 97154n; 97155n; 97156n; 97157n; 97158n; 97161y; 97162y; 97163y; 97164y; 97165y; 97166y; 97167y; 97168y; G0380y; G0381y; G0382y; G0383y; G0384y; G0406y; G0407y; G0408y; G0410y; G0411y; G0425y; G0426y; G0427y; G0451n; G0459n; G0463y; G0508y; G0509y; Check E&M Codes as well (99201 – 99497)
96125 Standardized Cognitive Performance Testing Y 36591n; 36592n;; 96127n; 96146n; 96160y; 96161y; 96523n; 97151n; 97152n; 97153n; 97154; 97155n; 97156n; 97157n; 97158n
29581 Multi-Layer Compression System – Below Knee N 29540y; 29550y; 29580y; 97140y; 97535y
29584 Multi-Layer Compression System – Entire Arm N 29125y; 29126y; 29130y; 29131y; 97140y; 97535y
97012 Mechanical Traction N 96523n; 97018y; 97140y; 97164y; 97168y
G0281 Electrical Stimulation – Stage 3-4 Wounds N 96523n; 97032y; G0283y; 97164y; 97168y
G0283 Electrical Stimulation – Other Than Wound Care N 96523n; 97032y; 97164y; 97168y
97016 Vasopneumatic Device N 96523n; 97018y; 97026y; 97164y; 97168y
97018 Paraffin Bath N 96523n; 97022y; 97164y; 97168y
97022 Whirlpool N 96523n; 97164y; 97168y
97024 Diathermy N 96523n; 97018y; 97026y; 97164y; 97168y
97026 Infrared N 96523n; 97018y; 97022y; 97164y; 97168y
97028 Ultraviolet N 96523n; 97018y; 97022y; 97026y; 97164y; 97168y
97032 Electrical Stimulation, Manual Y 96523n; 97164y; 97168y
97033 Iontophoresis Y 96523n; 97164y; 97168y
97034 Contrast Bath Y 96523n; 97164y; 97168y
97035 Ultrasound Y 96523n; 97164y; 97168y
97036 Hubbard Tank Y 96523n; 97164y; 97168y
97039 Unlisted Modality Y 96523n; 97164y; 97168y
97110 Therapeutic Exercises Y 96523n; 97164y; 97168y
97112 Neuromuscular Re-education Y 96523n; 97022y; 97036y; 97164y; 97168y
97113 Aquatic Therapy/Exercises Y 96523n; 97022y; 97036n; 97110y; 97164y; 97168y
97116 Gait Training Y 96523n; 97164y; 97168y
97124 Massage Y 96523n; 97164y; 97168y
97127 Therapeutic Interventions for Cognitive Function N 96523n; 97155n; 97164y; 97168y; 0373n
97139 Physical Medicine Procedure Y 96523n; 97164y; 97168y
97140 Manual Therapy Y 96523n; 95851y; 95852y; 97018y; 97124n; 97164y; 97168y; 97530y; 97750y
97150 Group Therapeutic Procedures N 96523n; 97110y; 97112y; 97113y; 97116y; 97124y; 97127y; 97140y; 97153n; 97154n; 97155n; 97156n; 97157n; 97158n; 97164y; 97168y; 97530y; 97532y; 97533y; 97535y; 97537y; 97542y; 97760y; 97761y; 97763y; G0515y; 0373Tn
97151 Behavior Identification Assessment Y 0403Tn; 0488Tn; 36591n; 36592n; 90867n; 90868n; 90869n; 90882n; 90889n; 96160y; 96161y; 96523n
97152 Behavior Identification – Supporting Assessment Y 0403Ty; 0488Ty; 36591n; 36592n; 90867n; 90868n; 90869n; 90889n; 96160y; 96161y; 96523n
97153 Adaptive Behavior Treatment by Protocol Y 0403Ty; 0488Ty; 36591n; 36592n; 90867n; 90868n; 90869n; 90882n; 90889n; 92508n; 96523n; 97127n
97154 Group Adaptive Behavior Treatment by Protocol Y 0403Ty; 0488Ty; 36591n; 36592n; 90867n; 90868n; 90869n; 90882n; 90889n; 96523n; 97127n
97155 Adaptive Behavior Treatment by Protocol Modification Y 0403Ty; 0488Ty; 36591n; 36592n; 90867n; 90868n; 90869n; 90882n; 90889n; 96523n
97156 Family Adaptive Behavior Treatment Guidance Y 0403Ty; 0488Ty; 36591n; 36592n; 90867n; 90868n; 90869n; 90882n; 90889n; 96523n; 97127n
97157 Multiple-Family Group Adaptive Behavior Treatment Guidance Y 0403Ty; 0488Ty; 36591n; 36592n; 90867n; 90868n; 90869n; 90882n; 90889n; 96523n; 97127n
97158 Group Adaptive Behavior Treatment by Protocol Modification Y 0403Ty; 0488Ty; 36591n; 36592n; 90785y; 90791n; 90792n; 90832n; 90833y; 90834n; 90836y; 90837n; 90838y; 90839n; 90840y; 90845n; 90846n; 90847n; 90849n; 90853n; 90863y; 90865n; 90867; 90868n; 90869n; 90870n; 90875y; 90876y; 90880n; 90882n; 90885n; 90887n; 90889n; 92507n; 96523n; 97127n; 97150y
97161 Physical Therapy Evaluation – Low Complexity N 95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 96105y; 96125y; 96130y; 96132y; 96136y; 96138y; 96146y; 96150n; 96151n; 96152; 96153n; 96154n; 97164n; 97750y; 97755y; 97762n; 97763n; G0270n; G0271n; G0463y; G0505y; G0508y; G0509y
97162 Physical Therapy Evaluation – Moderate Complexity N 95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 96105y; 96125y; 96130y; 96132y; 96136y; 96138y; 96146y; 96150n; 96151n; 96152; 96153n; 96154n; 97161n; 97164n; 97750y; 97755y; 97762n; 97763n; G0270n; G0271n; G0463y; G0505y; G0508y; G0509y
97163 Physical Therapy Evaluation – High Complexity N 95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 96105y; 96125y; 96150n; 96130y; 96132y; 96136y; 96138y; 96146y; 96151n; 96152; 96153n; 96154n; 97161n; 97162n; 97164n; 97750y; 97755y; 97762n; 97763n; G0270n; G0271n; G0463y; G0505y; G0508y; G0509y
97164 Physical Therapy Re-evaluation N 95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 96105y; 96125y; 96130y; 96132y; 96136y; 96138y; 96146y; 96150n; 96151n; 96152; 96153n; 96154n; 97750y; 97755y; 97762n; 97763n; G0270n; G0271n; G0463y; G0505y; G0508y; G0509y
97165 Occupational Therapy Evaluation – Low Complexity N 95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 96105y; 96125y; 96130y; 96132y; 96136y; 96138y; 96146y; 96150n; 96151n; 96152; 96153n; 96154n; 97151n; 97152n; 97168n; 97750y; 97755y; 97762n; 97763n; G0270n; G0271n; G0463y; G0505y; G0508y; G0509y
97166 Occupational Therapy Evaluation – Moderate Complexity N 95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 96105y; 96125y; 96130y; 96132y; 96136y; 96138y; 96146y; 96150n; 96151n; 96152; 96153n; 96154n; 97151n; 97152n; 97168n; 97750y; 97755y; 97762n; 97763n; G0270n; G0271n; G0463y; G0505y; G0508y; G0509y
97167 Occupational Therapy Evaluation – High Complexity N 95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 96105y; 96125y; 96130y; 96132y; 96136y; 96138y; 96146y; 96150n; 96151n; 96152; 96153n; 96154n; 97151n; 97152n; 97168n; 97750y; 97755y; 97762n; 97763n; G0270n; G0271n; G0463y; G0505y; G0508y; G0509y
97168 Occupational Therapy Re-evaluation N 95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 96105y; 96125y; 96130y; 96132y; 96136y; 96138y; 96146y; 96150n; 96151n; 96152; 96153n; 96154n; 97151n; 97152n; 97168n; 97750y; 97755y; 97762n; 97763n; G0270n; G0271n; G0463y; G0505y; G0508y; G0509y
97530 Therapeutic Activities Y 95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 96523n; 97113y; 97116y; 97127y; 97153n; 97154n; 97155n; 97156n; 97157n; 97158n; 97164y; 97168y; 97533y; 97535y; 97537y; 97542y; 97750y; G0515y; 0373Tn
97533 Sensory Integration Y 96523n; 97164y; 97168y
97535 Self Care/Home Management Training Y 96523n; 97153n; 97154n; 97155n; 97156n; 97157n; 97158n; 97164y; 97168y; 0373Tn
97537 Community/Work Reintegration Y 96523n; 97164y; 97168y
97542 Wheelchair Management – Assessment and Training Y 96523n; 97164y; 97168y
97545 Work Hardening; First 2 Hours Y 96523n; 97140n; 97164y; 97168y
97597 Wound Care Selective First 20 Square Centimeters N 17250y; 29105y; 29125y; 29126y; 29130y; 29131y; 29200y; 29240y; 29260y; 29280y; 29305y; 29325y; 29345y; 29355y; 29358y; 29365y; 29405y; 29425y; 29435y; 29440y; 29445y; 29450y; 29505y; 29515y; 29520y; 29530y; 29540y; 29550y; 29580y; 29581y; 29582y; 29583y; 29584y; 96523n; 97022y; 97164y; 97602n; 97605y; 97606y; 97607y; 97608y; 97610y, 99451n; 99452n; G0471y
97598 Wound Care Selective; Each additional 20 Square Centimeters or Any Part Thereof N 29105y; 29125y; 29126y; 29130y; 29131y; 29200y; 29240y; 29260y; 29280y; 29305y; 29325y; 29345y; 29355y; 29358y; 29365y; 29405y; 29425y; 29435y; 29440y; 29445y; 29450y; 29505y; 29515y; 29520y; 29530y; 29540y; 29550y; 29580y; 29581y; 29582y; 29583y; 29584y; 96523n; 97022y; 97164y; 97602n; 97605y; 97606y; 97607y; 97608y; 97610y, G0471y
97602 Wound Care Non-Selective N 29105y; 29125y; 29126y; 29130y; 29131y; 29200y; 29240y; 29260y; 29280y; 29305y; 29325y; 29345y; 29355y; 29358y; 29365y; 29405y; 29425y; 29435y; 29440y; 29445y; 29450y; 29505y; 29515y; 29520y; 29530y; 29540y; 29550y; 29580y; 29581y; 29582y; 29583y; 29584y; 96523n; 97164y; 97607n; 97608n
97605 Negative Pressure Wound Therapy ≤ to 50 Square Centimeters N 96523n; 97164y; 97607y; 97608n
97606 Negative Pressure Wound Therapy ﹥50 Square Centimeters N 96523n; 97164y; 97607n; 97608y
97610 Low Frequency, Non-Contact, Non-Thermal Ultrasound N 96523n; 97035y; 97602n; 97607y; 97608y
97750 Physical Performance Test or Measurement Y 95831n; 95832n; 95833n; 95834n; 95851n; 95852n; 96523n; 97150n
97755 Assistive Technology Assessment Y 96523n; 97035y; 97110y; 97112y; 97127y; 97140y; 97530y; 97532y; 97533y; 97535y; 97537y; 97542y; 97545y; 97750n; 97760y; 97761y; 97762n; 97763y;
97760 Orthotic Management & Training, Initial Orthotic(s) Encounter Y 0213Ty; 0216Ty; 0228Ty; 0229Ty; 0230Ty; 0231Ty; 29044y; 29046y; 29049y; 29055y; 29058y; 29065y; 29075y; 29085y; 29105y; 29125y; 29126y; 29130y; 29131y; 29200y; 29240y; 29260y; 29280y; 29505y; 29515y; 29520y; 29530y; 29540y; 29550y; 29580y; 29581y; 29582y; 29583y; 29584y; 96523n; 97016y; 97110y; 97112y; 97116y; 97124y; 97140y; 97164y; 97168y; 97762y; 97763n
97761 Prosthetic Management & Training, Initial Prosthetic(s) Encounter Y 0213Ty; 0216Ty; 0228Ty; 0229Ty; 0230Ty; 96523n; 97016y; 97110y; 97112y; 97116y; 97124y; 97140y; 97164y; 97168y; 97760y; 97762y; 97763n
97763 Orthotic/Prosthetic Management and/or Training, Subsequent Orthotic/Prosthetic Encounter(s) Y 0213Ty; o216Ty; 0228Ty; 0229Ty; 0230Ty; 0231Ty; 29044y; 29046y; 29049y; 29055y; 29058y; 29065y; 29075y; 29085y; 29105y; 29125y; 29126y; 29130y; 29131y; 29200y; 29240y; 29260y; 29280; 29305y; 29325y; 29345y; 29355y’ 29358y; 29365y; 29405y; 29425y; 29435y; 29440y; 29445y; 29450y; 29505y; 29515y; 29520y; 29530y; 29540y; 29550y; 29580y; 29581y; 29584y; 96523n; 97016y; 97110y; 97112; 97116y; 97124y; 97140y
G0515 Development of Cognitive Skills Y 96523n; 97164y; 97168y

How do I bill for an initial evaluation or re-evaluation?

As of January 1, 2017, PTs and OTs should no longer use the CPT codes 97001, 97002, 97003, and 97004 to bill for initial evaluations and re-evaluations. That’s because these codes have been replaced by a new set of eight evaluative codes: two for re-evaluations and six for evaluations.

But, this isn’t a simple swap-out. That’s because the new codes for initial evaluations are tiered according to the complexity of the evaluation performed. So, PTs and OTs now must determine whether a patient evaluation is low complexity, moderate complexity, or high complexity—and then select the CPT code that correctly represents that level of complexity. Here’s a brief breakdown of the new codes:

Replacement CPT Codes for 97001

97161 Physical therapy evaluation: low complexity
97162 Physical therapy evaluation: moderate complexity
97163 Physical therapy evaluation: high complexity

Replacement CPT Codes for 97003

97165 Occupational therapy evaluation: low complexity
97166 Occupational therapy evaluation: moderate complexity
97167 Occupational therapy evaluation: high complexity

Replacement CPT Codes for 97002 and 97004

97164 Re-evaluation of physical therapy established plan of care requiring:

  1. An examination (including a review of history and use of standardized tests and measures)
  2. A revised plan of care (based on use of a standardized patient assessment instrument and/or measurable assessment of functional outcome)
97168 Re-evaluation of occupational therapy established plan of care requiring:

  1. An assessment of changes in patient functional or medical status, along with a revised plan of care
  2. An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals
  3. A revised plan of care (a formal re-evaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required)

Looking for more in-depth guidance on how to select the correct level of complexity for each PT or OT evaluation? Check out this blog post, this blog post, and this webinar.

When should I bill for an evaluation vs. a re-evaluation?

On the surface, the difference between billing an initial eval and a re-evaluation may seem straightforward, but that’s not always the case. Keep reading for three example scenarios to help you make what can occasionally be a challenging decision (adapted from this post by WebPT’s Kylie Mckee). For several more examples, check out the post in full.

Scenario 1

According to McKee, if a current patient develops a newly diagnosed—yet related—condition, then you’ll want to perform and bill for a re-eval using code 97164. For example, if a high-school soccer player is receiving care for left patellofemoral pain syndrome and develops similar symptoms in his or her right knee, then you would perform (and bill) for a re-eval and update the existing plan of care. After all, as Mckee explains, “a re-evaluation is triggered by a significant clinical change in the condition for which the original plan of care was established.” The patient should now be receiving care for bilateral patellofemoral pain syndrome.

Scenario 2

If a current patient develops a newly diagnosed—yet unrelated—condition, then you’ll want to perform and bill an initial evaluation. For example, if the same soccer-playing patient who has been receiving care for bilateral patellofemoral pain syndrome shows up with lower back pain related to scoliosis, then you would want to perform and bill for an initial evaluation using codes 97161–97163. After all, “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.”

Scenario 3

If a former patient returns to therapy after discharge and requests care for the same issue you were treating previously, you would most likely perform an initial evaluation using codes 97161–97163. McKee cautions that there isn’t a whole lot of formal guidance on how to handle this scenario, but if it’s been 60 days since the patient received care from you, Medicare requires you to begin a new case. And because you’ve already discharged the patient, it makes sense that you would start over if that patient say, reinjures his or her left rotator cuff and needs your services again. For commercial payers, though, you should defer to the payer’s rules—and, as always, your state practice act.

Should I bill for a re-evaluation each time I complete a progress note?

A typical progress note, even one with functional limitation reporting, does not require a re-evaluation CPT code (97164 or 97168). In fact, you should only ever bill for a re-evaluation if one of the following situations apply:

  • The professional assessment 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 for that interval.
  • There are new clinical findings.
  • The patient fails to respond to the treatment outlined in the current plan of care.

For more detailed information on when and how to bill for a re-evaluation, check out this blog post.

Where can I find the physician fee schedule final rule?

The CY 2019 Physician Fee Schedule Final Rule is available here. We’ve also written a summary of final rule changes affecting rehab therapists. You can read that here.


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By Heidi Jannenga

April 22, 2019