Pt re-eval est plan care
CPT 97164 is billed when a physical therapist re-evaluates a patient who is already receiving therapy to determine if the treatment plan needs to be modified. This is different from the initial evaluation and focuses on measuring progress and adjusting goals.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Bill 97164 only when the re-evaluation results in documented plan of care modifications, not for routine progress checks
Impact: $67.60 at risk - Medicare audits frequently deny re-evals without evidence of meaningful clinical change requiring plan modification
Time interval between evaluations matters - Medicare expects reasonable spacing (typically 30+ days) unless acute change documented
Impact: Re-evaluations billed within 2-3 weeks of initial eval or previous re-eval face 40-60% higher denial rates without documented medical necessity
Always append modifier GP to identify this as physical therapy; claim will auto-deny without it
Impact: 100% payment denial without GP modifier - this is non-negotiable for Medicare and most commercial payers
Document specific standardized outcome measures (LEFS, DASH, Oswestry, etc.) with numerical scores to justify re-evaluation
Impact: Claims with documented functional outcome measures have 85% lower audit risk and faster payment processing
Do not bill 97164 on the same day as initial evaluation codes (97161-97163) - these are mutually exclusive
Impact: Automatic denial of $67.60 if billed same day as initial eval; NCCI edits bundle these codes on same date
Ensure re-evaluation is performed by PT only, not PTA - PTA-performed re-evals are not billable
Impact: Medicare Recovery Audit Contractors (RACs) specifically target this - can result in $67.60 recoupment plus penalties per incident
Common denials
Missing or incorrect therapy modifier (GP not appended)
How to appeal: Resubmit claim with corrected modifier GP. Include cover letter explaining clerical error. Most payers allow corrected claim submission within 1 year of service date without formal appeal.
Insufficient documentation of meaningful clinical change or plan modification
How to appeal: Submit formal appeal with complete therapy notes highlighting specific functional changes, updated goals, and treatment plan modifications. Include before/after functional outcome measure scores demonstrating measurable change (minimum 10-15% improvement or decline). Reference LCD article for therapy services.
Re-evaluation billed too soon after initial evaluation or previous re-evaluation without documented acute change
How to appeal: Provide detailed clinical narrative explaining unexpected change in patient status, new diagnosis, exacerbation, or other acute event necessitating early re-assessment. Include physician orders or referral if condition changed. Compare to initial eval findings to demonstrate significant variance.
Service performed by PTA rather than licensed PT
How to appeal: This is generally not appealable as it violates Medicare policy. If PT actually performed service, submit corrected documentation with PT signature, credentials, and attestation. If PTA performed service, write off charge and implement compliance training to prevent recurrence.
Frequently asked questions
How much does Medicare pay for CPT 97164 in 2025?
Medicare pays $67.60 for CPT 97164 in 2025 based on the national average rate. Both facility and non-facility rates are identical at $67.60. The total RVU is 2.09 multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary slightly by geographic locality based on GPCI adjustments.
What is the difference between 97164 and 97161-97163?
CPT 97161-97163 are initial physical therapy evaluation codes for new patients or new conditions, varying by complexity level. CPT 97164 is a re-evaluation code used only for established patients already receiving PT to assess progress and modify the treatment plan. You cannot bill an initial eval and re-eval on the same date of service.
How often can you bill CPT 97164 for the same patient?
There is no specific Medicare frequency limit for 97164, but medical necessity must be documented for each occurrence. Most payers expect re-evaluations every 30-90 days during active treatment. Billing more frequently requires documentation of significant functional change, new symptoms, or clinical events justifying early re-assessment. Over-utilization triggers audits.
Can a physical therapist assistant perform CPT 97164?
No. CPT 97164 must be performed and documented entirely by a licensed Physical Therapist (PT). Physical Therapist Assistants (PTAs) cannot conduct evaluations or re-evaluations under Medicare rules and most state practice acts. If a PTA performs the service, it is not billable and payment will be recouped if audited.
What modifiers are required for billing CPT 97164?
Modifier GP is mandatory for Medicare and most payers to identify the service as physical therapy. Without GP, the claim will deny. Additional modifiers like 59 (distinct service), 76 (repeat procedure), or KX (therapy cap exception) may be needed based on specific circumstances, but GP is always required for physical therapy re-evaluations.
What documentation is required to support CPT 97164?
Documentation must include updated subjective and objective findings, standardized functional outcome measures with scores, comparison to previous evaluation, clinical reasoning for re-evaluation timing, and modified plan of care with updated goals and interventions. The PT must personally sign the documentation. Missing any element significantly increases audit and denial risk.
Can you bill 97164 on the same day as physical therapy treatment codes?
Yes, you can bill 97164 with treatment codes (97110, 97112, 97116, 97140, etc.) on the same date if both services are performed and documented separately. Consider adding modifier 59 to 97164 if payer edits bundle them together. Ensure documentation clearly distinguishes re-evaluation activities from treatment interventions to support separate payment of $67.60 plus treatment code reimbursement.