For practices in the US

CPT Codes for Physical Therapy Evaluations: 97161, 97162, 97163 and 97164

There isn't one CPT code for a physical therapy evaluation. There are three evaluation codes, chosen by complexity: 97161 (low), 97162 (moderate) and 97163 (high). A fourth code, 97164, is for re-evaluations. The level you bill has to match what the evaluation note documents across four components: history, examination, clinical presentation and clinical decision making. This guide walks through each component, shows what documentation supports each level, and covers the re-evaluation rules and common denials.

CPT codes belong to the American Medical Association, and payers set their own coverage rules. This summary is based on the APTA evaluation code reference and Chapter 15 of the Medicare Benefit Policy Manual. Rules change, so confirm anything you're unsure about with your Medicare contractor and each commercial, Medicaid or workers' comp payer before you bill.

The three evaluation levels at a glance

A few things to know before you pick a code:

• The evaluation codes are untimed. You bill one unit whatever the length of the visit. The typical times are guidance only and don't decide the level.
• Evaluation minutes don't count toward timed codes. Medicare's manual says evaluation minutes are part of the total treatment minutes, but must not be included in the minutes you use to bill timed codes such as 97110 or 97140 on the same day.
• These codes replaced 97001 and 97002 in 2017. APTA notes that some workers' comp and auto payers may still use the older codes, so check each fee schedule.
• Higher complexity doesn't always pay more. Medicare's fee schedule has valued the three levels the same, while some Medicaid and commercial schedules pay them differently. Pick the level the documentation supports, not the one you expect to pay best.

The four complexity components

All four components are required to report a level. Here's what each one means and what the note needs to show.

History: personal factors and comorbidities

Personal factors include things like age, sex, coping style, social background, education, occupation, past and current experience, and behavior patterns: anything that shapes how the patient experiences their disability. Comorbidities are other conditions.

The important qualifier is that they must affect the plan of care. A patient may have diabetes, but if it doesn't change your plan, it doesn't count toward complexity. Document the factor and how it affects the plan:

Lives alone in a second-floor apartment with no elevator; return to independent stair climbing is a priority goal and limits discharge planning.

Type 2 diabetes with peripheral neuropathy: reduced plantar sensation affects balance training progression and requires skin checks after weight-bearing exercise.

Examination: body systems and elements

The examination is counted in elements, drawn from three categories: body structures and functions, activity limitations, and participation restrictions. APTA's reference also defines the body systems a systems review covers (cardiovascular/pulmonary, integumentary, musculoskeletal, neuromuscular, and communication, affect, cognition, language and learning style).

Make each element you tested easy to find and count. A note that says "strength and ROM WNL" in a single line is hard to credit as more than one element. Separate findings with headings or a short list:

• Body structures and functions: knee flexion AROM 0–95°, quadriceps strength 3+/5, effusion present
• Activity limitations: unable to descend stairs reciprocally, gait speed 0.7 m/s
• Participation restrictions: unable to return to work as a warehouse picker, has stopped attending weekly community bowling

Clinical presentation: stable, evolving or unstable

• Stable: uncomplicated, predictable characteristics.
• Evolving: clinical characteristics that are changing.
• Unstable: unpredictable characteristics.

This is the component that's easiest to leave unsupported, especially for 97163. Write a sentence that says what is changing or unpredictable and why, rather than just ticking a box. For example: "Presentation evolving: pain behavior and reported instability have changed over the past two weeks, with two near-falls since the last physician visit."

Clinical decision making

Clinical decision making is low, moderate or high complexity, and it should show your use of a standardized patient assessment instrument and/or a measurable assessment of functional outcome. Name the tool, give the score and explain what it means for the plan, for example: "LEFS 28/80, indicating severe functional limitation; goals and frequency set accordingly." The plan of care itself (goals, frequency, duration and interventions) is part of the evaluation.

When the components point to different levels

Because every component is required, you report the highest level that all four components support. In practice, the lowest-scoring component sets the CPT code for the PT evaluation.

Say a patient has three comorbidities that affect the plan (high), you examine four elements (high), but the presentation is stable (low). That evaluation is 97161, not 97163. If the presentation really was evolving, the note needs to say so and explain why; if it doesn't, a reviewer will read it as stable.

What documentation supports each level

These examples show the kind of documentation that lines up with each code. They're illustrations of coding logic, not clinical guidance.

97161 CPT code: low complexity

A healthy adult with lateral ankle pain after a sprain. No personal factors or comorbidities affect the plan. The exam addresses two elements: ankle range of motion (a body structure and function) and walking on uneven ground (an activity limitation). The presentation is stable, and decision making is straightforward, using a single outcome measure to set goals.

97162 CPT code: moderate complexity

A patient after a total knee replacement with obesity and a physically demanding job, both of which affect the plan. The exam addresses three elements: knee range of motion (a body structure and function), stair climbing (an activity limitation) and return to work (a participation restriction). Pain and mobility are changing week to week, so the presentation is evolving, and the plan has to weigh several factors.

97163 CPT code: high complexity

An older adult after a fall, with Parkinson's disease, diabetic neuropathy and a recent medication change, who lives alone. The exam covers four or more elements across several body systems. Blood pressure response to standing is unpredictable and balance varies between sessions, so the presentation is unstable. Decision making involves multiple standardized measures and coordination with the physician.

For any level, the note should make each component easy to locate. If a reviewer has to infer a component, assume it won't be credited.

97164: the PT re-evaluation CPT code

97164 is the re-evaluation of an established plan of care. It requires an examination that reviews the history and uses standardized tests and measures, and a revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome. Typical face-to-face time is 20 minutes, and like the evaluation codes it's untimed.

When Medicare covers a re-evaluation

Medicare's manual says a re-evaluation is not a routine, recurring service. It's covered only when the documentation supports the need for further tests and measurements after the initial evaluation. The listed indications are:

• New clinical findings
• A significant change in the patient's condition (improvement or decline) that wasn't anticipated in the plan of care
• Failure to respond to the interventions in the plan of care

A re-evaluation may also be appropriate before a planned discharge, to determine whether goals have been met or to inform the physician or the next setting of care.

What isn't a re-evaluation

• Progress reports. Medicare requires a progress report at least once every 10 treatment days. Medicare's manual says a re-evaluation shouldn't be required routinely before every progress report.
• Recertifications. Recertifying the plan of care doesn't by itself justify billing 97164.
• Routine weekly assessments. Continuous assessment of progress is part of ongoing treatment and isn't payable as a re-evaluation.
• State practice act requirements. Some states require re-evaluation at set intervals, but for Medicare payment the re-evaluation must still meet Medicare's coverage rules.

Commercial payers often follow similar logic, but some limit re-evaluations by number or interval. Check each payer's policy.

Re-evaluation or new evaluation?

Medicare's manual says an evaluation is warranted, for example, for a new diagnosis or when a condition is treated in a new setting. It also treats a new condition that starts during an active PT episode as part of the same episode. Whether that calls for 97164 or a new evaluation code isn't always clear-cut, and payers handle it differently. If a patient returns after discharge or presents with a new problem, check with the payer before choosing the code.

Common denials for physical therapy eval codes

• Level not supported. The billed level is higher than one or more components in the note, often because the presentation or decision making isn't explained.
• Routine re-evaluations. 97164 billed at every recertification or progress report, with no new findings, significant change or failure to respond documented.
• Evaluation not performed by a PT. Under Medicare, only the clinician can perform the evaluation or re-evaluation. A PTA's measurements can be included, but the PT must actively and personally take part, not just summarize someone else's findings.
• Evaluation minutes counted twice. Minutes spent evaluating are added to timed-code minutes, inflating timed units.
• Missing therapy modifier. Medicare requires the GP modifier on outpatient PT services, and many other payers do too.
• No certified plan of care. For Medicare, the plan of care needs a physician's or nonphysician practitioner's certification. When the evaluation is the only service, the referral or order is treated as the certification. Since January 1, 2025, a signed and dated order or referral for physical therapy can stand in for the physician's or NPP's signature on the initial plan of care, if your record shows you sent them the plan within 30 calendar days of the evaluation. Recertifications still need their signature.
• Same-day code edits. National Correct Coding Initiative (NCCI) edits can deny codes billed together on the same day. Check the current NCCI procedure-to-procedure edit tables, and only use modifier 59 or an X modifier when the documentation meets CMS's criteria (see CMS's guide to modifiers 59, XE, XP, XS and XU).

A quick pre-billing check for every evaluation

1. Each personal factor and comorbidity you counted is linked to the plan of care.
2. Examination elements are listed separately and can be counted.
3. The clinical presentation is stated and explained in a sentence.
4. At least one named standardized tool or measurable functional outcome appears, with a score.
5. The code matches the lowest of the four components.
6. Evaluation minutes are recorded separately from timed treatment minutes.
7. For a re-evaluation, the reason is one of the payer's covered indications and is written in the note.
8. The GP modifier and any certification the payer needs are in place.

Build the components into your evaluation template

Level disputes often come down to documentation that's hard to read, not care that wasn't complex. Setting up your evaluation template so each component has its own section makes the code choice obvious and easy to defend.

In Caspen, you can build progress note templates with dropdowns, checkboxes and tables, so a PT evaluation template can have a field for each personal factor and comorbidity, a section per examination element, a clinical presentation selector with a space to explain it, and outcome measure scores. Caspen AI can draft the evaluation note into that template from the recorded session, for the therapist to review and save. See how Caspen works for physical therapy practices.

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