CPT 97164Physical Therapy

Pt re-eval est plan care

CPT code 97164 covers a physical therapist's re-evaluation of a patient who is already receiving treatment, assessing progress and updating the care plan. This is not an initial evaluation, but rather a check-in to see if the treatment approach needs adjustment based on the patient's response to therapy.

Showing rates for

National Average

Base Medicare rate

$67.60

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

0.96

PE RVU (NF)

1.11

MP RVU

0.02

Total RVU

2.09

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

Loading bundling edits…

Billing tips

Bill 97164 only when performing a comprehensive re-evaluation with modified plan of care, not for routine daily progress notes
Impact: Prevents audits and recoupment; documentation must support clinical decision-making justifying $67.60 service versus included progress notes
Time Medicare re-evaluations strategically at natural decision points (every 10 visits, 30 days, or significant status change) rather than arbitrary intervals
Impact: Improves medical necessity documentation and reduces denial risk; payer-specific policies may limit frequency to every 30 days or 10 visits
Document specific functional changes with objective measurements (ROM, strength grades, gait speed, outcome measure scores) that justify plan modifications
Impact: Strengthens medical necessity defense; vague documentation is the #1 reason for re-evaluation denials representing $67.60 per instance
Never bill 97164 on the same day as initial evaluation codes (97161-97163) for the same patient
Impact: These services are mutually exclusive; billing both triggers automatic denial and potential fraud investigation
Verify payer-specific re-evaluation policies before billing; some commercial payers limit frequency or require prior authorization
Impact: Medicare allows medically necessary frequency, but some payers limit to 1 per 30 days or episode, preventing $67.60 reimbursement
Ensure PTAs do not perform or sign re-evaluations; this must be completed by licensed PT only per Medicare regulations
Impact: PTA-performed re-evaluations result in 100% payment denial and potential recoupment of all therapy services in that episode

Live Field Datano reports yet

Real billers contribute denial patterns and appeal strategies for this code. Once 5+ reports come in, you’ll see live aggregated data here — the only place this exists, free.

Working with CPT 97164?

Get the free Revenue Protection Toolkit — the denial triggers, modifier pitfalls, and bundling conflicts that quietly cost you reimbursement. Instant download.

Help build the field knowledge

MedPayIQ gets smarter as billers contribute. If you've had this code denied, share what happened so others learn from it. Anonymous, no patient info.

Related actions

Frequently asked questions

How often can you bill CPT code 97164 for the same patient?

Medicare does not set a specific frequency limit for 97164, but medical necessity must be documented for each re-evaluation. Most payers accept re-evaluations every 30 days or every 10 visits, but you can bill more frequently if there is a significant change in patient status, unexpected decline, or medical complication. Always document the clinical rationale for timing. Some commercial payers have specific policies limiting frequency to once per 30 days or once per episode.

What is the Medicare reimbursement rate for CPT 97164 in 2025?

The 2025 Medicare national average reimbursement for CPT 97164 is $67.60 for both facility and non-facility settings. This is based on 2.09 total RVUs (0.96 work RVU, 1.11 practice expense RVU, 0.02 malpractice RVU) multiplied by the 2025 conversion factor of 32.3465. Actual payment may vary based on geographic adjustment and payer-specific rates.

Can a physical therapist assistant (PTA) perform a re-evaluation coded as 97164?

No, PTAs cannot perform or bill for re-evaluations under Medicare and most payer regulations. CPT 97164 requires the clinical decision-making and assessment skills of a licensed Physical Therapist (PT). If a PTA performs the service, the claim will be denied entirely. PTAs can perform treatment interventions and contribute to progress notes, but formal re-evaluations must be completed and signed by the supervising PT.

What is the difference between CPT 97164 and daily progress notes?

CPT 97164 is a comprehensive re-evaluation involving systematic reassessment of functional status, treatment response, and plan of care modification with updated goals and interventions. Daily progress notes document routine treatment sessions and are included in treatment codes (97110, 97140, etc.), not separately billable. Re-evaluations require clinical decision-making to change the care plan, while progress notes track ongoing implementation of the existing plan. Only bill 97164 when you formally modify the treatment approach based on comprehensive reassessment.

Can you bill 97164 and treatment codes on the same day?

Yes, you can bill CPT 97164 with treatment codes (97110, 97140, 97530, etc.) on the same day. The re-evaluation is separately payable from therapeutic interventions. However, ensure the documentation clearly distinguishes the re-evaluation time and activities from the treatment session. The re-evaluation should be documented separately with all required elements, and treatment interventions should have their own timed notes. Always use modifier GP for Medicare physical therapy services.

What documentation is required to support billing CPT 97164?

Documentation must include: comparison of current to previous functional status with objective measurements, assessment of treatment response, modified or confirmed goals, revised plan of care with specific intervention changes, clinical rationale for re-evaluation timing, updated prognosis, and licensed PT signature with credentials. Include standardized outcome measures when possible (LEFS, DASH, Oswestry). Vague statements like 'patient improving, continue current plan' are insufficient and will result in denials during audits.

When is it medically necessary to perform a physical therapy re-evaluation?

Medical necessity exists when: patient shows significant functional improvement or decline requiring goal modification, patient plateaus requiring treatment approach changes, new complications or comorbidities emerge affecting therapy, payer requires periodic re-evaluation for continued authorization, patient needs discharge planning assessment, or treatment is not producing expected outcomes requiring plan revision. Simply reaching a time interval (30 days) without functional status changes does not automatically justify re-evaluation. Document the specific clinical reason.