CPT 97168Physical Therapy

Ot re-eval est plan care

CPT 97168 is used when an occupational therapist re-evaluates a patient who is already receiving therapy to determine if the treatment plan needs adjustments based on progress or changes in the patient's condition.

Showing rates for

National Average

Base Medicare rate

$69.54

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)

1.16

MP RVU

0.03

Total RVU

2.15

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

NCCI bundling edits

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Billing tips

Do not bill 97168 more frequently than every 10-14 treatment days or when significant change occurs
Impact: Medicare and most commercial payers have medical necessity thresholds; excessive re-evaluations can trigger audits and result in 30-50% denial rates for the code
Always append modifier GP to clearly identify the service as occupational therapy
Impact: Claims without GP modifier may be denied or misrouted, delaying payment of the full $69.54 by 30-60 days
Document specific functional changes or lack of expected progress that necessitate re-evaluation
Impact: Strong medical necessity documentation reduces denial risk by approximately 70% and supports the 2.15 RVU value assignment
Ensure re-evaluation results in a modified plan of care with updated goals, frequency, or interventions
Impact: Payers expect documented plan changes; failure to show modifications can result in downcoding or denial, losing the full $69.54 reimbursement
Do not bill 97168 on the same day as initial evaluation 97165-97167 for the same patient
Impact: These services are mutually exclusive per NCCI edits; billing both will result in automatic denial of one service
Bill 97168 separately from treatment codes (97530, 97110, etc.) and ensure time-based codes do not overlap with re-evaluation time
Impact: Proper time separation and documentation prevents bundling denials and ensures payment for both services, protecting approximately $70-150 in total reimbursement per session

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Frequently asked questions

How much does Medicare pay for CPT code 97168 in 2025?

Medicare pays $69.54 for CPT 97168 in 2025 under both facility and non-facility settings based on the national average. The code has a total RVU value of 2.15 (0.96 work RVU, 1.16 practice expense RVU, 0.03 malpractice RVU) multiplied by the conversion factor of 32.3465.

How often can you bill CPT 97168 for occupational therapy re-evaluation?

There is no specific Medicare frequency limit, but medical necessity must be established for each re-evaluation. Best practice is to perform re-evaluations every 10-14 treatment days, when significant functional change occurs, when progress plateaus unexpectedly, or when modifying the treatment plan is clinically warranted. More frequent billing increases audit risk.

What is the difference between CPT 97168 and 97110?

CPT 97168 is an occupational therapy re-evaluation to assess progress and modify the plan of care, while CPT 97110 is a treatment code for therapeutic exercises. 97168 is billed once per re-evaluation visit and involves comprehensive assessment, whereas 97110 is a time-based treatment code billed in 15-minute units for active therapeutic intervention.

Can you bill 97168 and treatment codes on the same day?

Yes, CPT 97168 can be billed on the same day as treatment codes like 97110, 97530, or 97535, but the time spent on re-evaluation must be clearly separated and documented distinctly from treatment time. The re-evaluation should result in documented plan modifications and cannot simply be routine progress assessment embedded in a treatment session.

What modifiers are required for CPT code 97168?

Modifier GP is required for all occupational therapy services including 97168 to identify the service as part of an OT plan of care. Additional modifiers may include 59 for distinct services, GT or 95 for telehealth, or 76 for repeat procedures by the same provider when medically necessary.

Does CPT 97168 require a physician order?

Yes, occupational therapy services including re-evaluations must be performed under a physician's plan of care. While the specific re-evaluation timing may be determined by the therapist based on clinical judgment, the overall therapy services must be ordered and periodically recertified by a physician or qualified non-physician practitioner.

What documentation is needed to support medical necessity for 97168?

Documentation must include objective evidence of functional change or lack of expected progress, comparison to previous evaluation findings, specific reasons why re-evaluation is needed at this time, standardized assessment results, updated measurable goals, and a modified plan of care showing concrete changes to treatment approach, frequency, or interventions based on re-evaluation findings.