When it is it appropriate to bill 97164?

Therapists often get confused between when they should bill a progress note and when they should bill a re-evaluation. However, there are extremely strict guidelines when it comes to using each code. 

Re-evaluations are not routine and shouldn’t be billed routinely. Progress notes are routine and are completed at every 10th visit or every 30 days (whichever comes first). 

According to Medicare, “Routine re-evaluations of expected progression in accordance with the plan of care, either during the episode of care or upon discharge, are not considered to be medically necessary separately billable services.” 

When medical necessity is supported, a re-evaluation (97164) is appropriate for:

  • A patient who is currently receiving therapy services and develops a newly diagnosed related condition e.g., a patient that is currently receiving therapy treatment for TKA. During the episode of care, the patient develops wrist pain. The clinician determines that the wrist pain is due to use of a walker which the patient is using as a result of the TKA. In this scenario, the wrist pain is a condition that is related to the TKA. Therefore, it is reasonable for the clinician to provide a re-evaluation of the patient due to this related condition.

  • A patient who is currently receiving therapy services and demonstrates a significant improvement, decline, or change in condition or functional status which was not anticipated in the plan of care and necessitates additional evaluative services to maximize the patient’s rehabilitation potential.

If it is appropriate to bill a re-eval, what should it include? 

On November 10, 2016, CMS published the following information regarding the re-evaluation code:

97164 – Re-evaluation of physical therapy established plan of care, requiring these components:  An examination including a review of history and use of standardized tests and measures is required; and a revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome. 

It is important to note that 97164 can be billed and bundled with other 97xxx codes with the addition of the 59 modifier to indicate the service is separate and distinct. It is also important to note that whenever a 59 modifier is on the claim, we need to indicate in the notes that the services are separate, distinct and medically necessary.

Still confused or have additional questions? Contact LRS at inquiries@lincolnrs.com and we can get them answered for you.