Ot re-eval est plan care
CPT code 97168 is used when an occupational therapist re-evaluates a patient who is already receiving treatment to assess their progress and update their care plan. This is different from an initial evaluation and happens when the patient's condition has changed or the therapist needs to reassess treatment goals.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Clearly document the medical necessity for the re-evaluation by identifying the specific change in patient status, new symptoms, or significant deviation from expected progress that triggered the re-assessment
Impact: Reduces denial risk by 60-70%; Medicare and commercial payers frequently deny re-evaluations performed without documented medical necessity or when they appear to be routine progress checks
Do not bill 97168 on the same day as initial evaluation codes (97165-97167); if transitioning a patient from another therapist or facility, wait at least one treatment session before performing a formal re-evaluation
Impact: Prevents automatic denial due to coding logic edits; same-day evaluation and re-evaluation billing is typically rejected as impossible
Time your re-evaluations strategically around certification periods for Medicare patients (every 30 days for SNF, every 60 days for home health) to align with required progress documentation
Impact: Maximizes reimbursement opportunity while meeting regulatory requirements; ensures the $69.54 re-evaluation is not considered administrative rather than billable
Include objective standardized assessment tools and measurable functional outcomes in your documentation to differentiate the re-evaluation from daily treatment notes
Impact: Increases clean claim rate by 40-50%; use of standardized measures (FIM, COPM, DASH) provides concrete evidence that a formal re-assessment occurred rather than routine treatment
Verify frequency limitations with the specific payer; while Medicare doesn't impose strict limits, many commercial payers limit re-evaluations to once every 30 days or require prior authorization for more frequent re-assessments
Impact: Prevents denials for exceeding frequency limits; proactive authorization can secure the $69.54 payment rather than facing retrospective denial
When billing 97168 with treatment codes on the same day, ensure total time documented supports both services and use modifier 59 or XE appropriately to indicate distinct services
Impact: Secures payment for both services; without proper modifier use, payers may bundle the re-evaluation into treatment and deny the separate $69.54 charge
Common denials
Medical necessity not established - payer states re-evaluation appears to be routine progress check rather than medically necessary re-assessment
How to appeal: Submit appeal with documentation highlighting specific triggering event: significant change in patient condition, new diagnosis, plateau in progress, change in medical status, or achievement of goals requiring new plan. Include physician orders if available and reference payer's own policy language regarding acceptable re-evaluation triggers. Compare baseline evaluation measures to current status to demonstrate meaningful change.
Frequency limitation exceeded - re-evaluation billed too soon after previous evaluation or re-evaluation without sufficient intervening treatment
How to appeal: Provide clinical justification for earlier-than-expected re-evaluation: acute decline in function, hospitalization, new injury, significant symptom change, or physician-requested re-assessment. Include treatment log showing intervening sessions. Reference Medicare guidance that allows re-evaluations when medically necessary regardless of timeframe. Request payer's specific policy on re-evaluation frequency if not clearly stated.
Bundled with treatment codes billed on same date of service - payer considers re-evaluation included in therapeutic procedure codes
How to appeal: Resubmit claim with modifier 59 or XE appended to 97168 to indicate separate and distinct service. Provide documentation showing re-evaluation was performed as distinct service with separate goals, assessment tools, and time from treatment session. Include time log showing when re-evaluation occurred versus treatment. Note that APTA and AOTA guidance support billing both when documentation supports distinct services.
Documentation does not support re-evaluation - reviewer determines documentation reflects routine treatment session rather than comprehensive re-assessment
How to appeal: Submit complete re-evaluation documentation including: patient history since last evaluation, review of current medications/medical status, standardized assessment results, comparison to prior functional levels, updated goal-setting with patient input, revised plan of care with specific interventions and frequency. Highlight use of objective measures and functional outcome tools. Include facility's re-evaluation template to demonstrate this meets organizational standards for comprehensive re-assessment versus progress note.
Frequently asked questions
What is the difference between CPT 97168 and a regular occupational therapy treatment session?
CPT 97168 is a comprehensive re-evaluation that includes formal reassessment using standardized tests, comparison to previous functional levels, goal revision, and plan of care modification. Regular treatment sessions (97530, 97535, etc.) focus on implementing interventions according to the established plan. A re-evaluation is more comprehensive, documents medical necessity for continuing or changing treatment approach, and typically takes more time than adjusting activities during routine treatment.
How often can occupational therapists bill CPT 97168 for the same patient?
Medicare does not specify a strict frequency limit for 97168 but requires medical necessity for each re-evaluation. Most commercial payers limit re-evaluations to once per 30 days unless medical necessity for more frequent re-assessment is documented. Re-evaluations are appropriate when there is significant change in patient condition, achievement or lack of progress toward goals, new symptoms, change in diagnosis, or physician request. Billing weekly re-evaluations will likely trigger denials unless exceptional circumstances are documented.
Can CPT 97168 be billed on the same day as occupational therapy treatment codes?
Yes, CPT 97168 can be billed on the same day as OT treatment codes (such as 97530, 97535, 97110) when both services are medically necessary and clearly distinct. However, you must append modifier 59 or XE to indicate separate services, document the time spent on each service separately, and ensure the re-evaluation documentation demonstrates a comprehensive reassessment rather than routine treatment adjustments. Many payers scrutinize same-day billing, so documentation must clearly support both services.
What is the Medicare reimbursement rate for CPT 97168 in 2025?
The 2025 Medicare national average payment rate for CPT 97168 is $69.54 for both facility and non-facility settings. This is based on 2.15 total RVUs (0.96 work RVU, 1.16 practice expense RVU, 0.03 malpractice RVU) multiplied by the 2025 conversion factor of 32.3465. Actual reimbursement may vary based on geographic locality adjustments and specific Medicare Administrative Contractor policies.
Do I need a physician referral to bill CPT 97168 for occupational therapy re-evaluation?
Medicare and most payers require a physician referral or certification for occupational therapy services, which typically covers both initial evaluations and re-evaluations. Some states allow occupational therapists to evaluate without referral under direct access laws, but Medicare requires physician certification. The re-evaluation must be within the scope of the original physician order or plan of care. If the re-evaluation identifies need for services beyond the original referral, an updated physician order may be required before proceeding with modified treatment.
Can occupational therapy assistants perform and bill CPT 97168?
No, occupational therapy assistants (OTA/COTA) cannot independently perform or bill CPT 97168. Re-evaluations must be conducted by a licensed occupational therapist (OTR/L). This is consistent with Medicare regulations and most state practice acts, which reserve evaluation and re-evaluation services for licensed therapists while allowing assistants to perform treatment under appropriate supervision. If an OTA identifies need for re-evaluation, the OTR must perform and document the service.
What documentation is required to justify medical necessity for CPT 97168?
Medical necessity documentation must include: the specific trigger for re-evaluation (change in patient condition, new symptoms, progress plateau, goal achievement, physician request, or significant deviation from expected outcomes); objective data from standardized assessment tools; comparison to previous functional levels; explanation of how findings will change the treatment plan; and updated goals with measurable outcomes. Simply noting 'routine re-evaluation' or 'per protocol' is insufficient and will likely result in denial. The documentation should demonstrate why a comprehensive re-assessment was necessary rather than continuing with current treatment plan.