CPT code 97161

CPT code 97161 is a billing code known as a low complexity evaluation and is a reflection of the history, examination of body systems and clinical presentation of a client condition. CPT code 97161 represents one level in a tiered system launched in 2017.

In 2017, physical therapists saw a few pivotal changes in billing and reporting practices that have carried forward. First, PQRS reporting requirements disappeared. Second, in January 2017 we saw the emergence of this new tiered system for physical therapy evaluation codes for Medicare and other commercial insurance payers which replaced the previous code for PT evaluation. 

Given that this new tiered system has been around since 2017, all therapists practicing in the outpatient setting should be familiar with them, but many may wish they understood the concept in more depth. 

In this article we will review the purpose and format for CPT codes, including physical therapy billing and dive into the first tier of evaluation codes, including CPT code 97161 or “low complexity evaluation.”

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CPT code review

Before we dive into the specifics of the PT evaluation or CPT code 97161, let’s review the definition and purpose of CPT codes in general. A therapist will select a CPT code based on the type of interventions they used and for how long they administered that intervention. These codes provide healthcare providers a uniform language of coding for medical services and procedures. CPT stands for Current Procedural Terminology codes and are utilized to describe the physical therapy services rendered when submitting a claim to a third party payer.

Some of the codes used commonly by physical therapists include:

• 97110: Therapeutic Exercise
• 97112: Neuromuscular Re-education
• 97116: Gait Training
• 97140: Manual Therapy
• 97530: Therapeutic Activity

All CPT codes are five digits and are either numeric or alphanumeric. Most of the physical therapy CPT coding falls into the 97000 series called Physical Medicine and Rehabilitation. It is important, however, to be familiar with relevant codes outside of this series because a PT can use any CPT code as long as it accurately describes the services provided and is allowed under their state licensure laws.

Components of proper physical therapy evaluations

If you are a licensed and practicing physical therapist, it is highly likely you are doing new patient evaluations. These patient encounters are essential for determining if a patient is a good candidate for physical therapy, for establishing a plan of care and for reporting to insurance companies and other third party payers why your care is medically necessary and therefore reimbursable.

A high quality patient evaluation should include the following components:

• Subjective examination and history: Patient interview and subjective outcome measures help you understand why your patient has sought care, what symptoms they are experiencing, what their functional limitations, participation restrictions and goals are as well as identify other environmental factors, personal factors and comorbidities that may impact the plan of care.

• Objective examination: The objective examination provides an overview of relevant body structure and function impairments and can also highlight activity limitations. It helps you determine where to direct your treatment. The information gleaned from the subjective and objective examination is also important to determine if a patient is appropriate to begin treatment or should be referred to a higher level of care like a specialist physician.

• Physical therapy diagnosis: The physical therapy diagnosis describes the functional and movement-related problems that necessitate physical therapy intervention. Selecting appropriate ICD 10 diagnosis codes is also an essential part of your new patient evaluation. These codes identify a medical and often functional diagnosis, but perhaps more importantly, they help insurance companies understand why the care you are providing is medically necessary and therefore, reimbursable.

• Prognosis: Prognosis qualifies the likelihood of a positive change in symptoms and function as a result of your treatment interventions. It helps determine your plan of care and justify your decision to treat a patient.

• Evaluation: During the evaluation you discuss the “so what” aspect of your exam findings. The evaluation links your exam findings with the patient’s functional limitations as well as your opinion on why they will benefit from skilled physical therapy. It also establishes the stability of the patient’s clinical presentation. In other words, is their presentation stable, evolving or unstable.

• Plan of Care: The plan of care states how frequently you will treat the patient, how long you anticipate you will work with the patient, and the interventions you intend to utilize during the plan of care.

• Goals: Short- and long-term goals should be time-based, specific and functional.

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CPT code 97161: Low complexity evaluation

Once you have documented all of the information outlined above, it is time to bill.

Currently, during the initial evaluation, there are three physical therapy diagnosis codes to select from based on level of complexity:

• 97161: Low complexity evaluation

• 97162: Moderate complexity evaluation

• 97163: High complexity evaluation

While the American Physical Therapy Association hoped that this tiered system would lead to beneficial reform in payment structures by Centers for Medicare and Medicaid Services, six years have passed since the introduction of these three new evaluation codes and Medicare continues to reimburse each code at the same rate, no matter the duration of the evaluation. 

Still, it is important that we utilize CPT code 97161, 97162 and 97163 correctly even if they are not yet linked to variations in reimbursement.

The level of complexity for a given patient evaluation is based on three components: 

• History

• Examination of body systems and

• Clinical presentation

The chart outlined below lists these components as they relate to each tier of complexity. It is important to note that even if the patient meets some of the criteria for a moderate or high complexity evaluation, if there is even one component that matches the criteria of the low complexity tier, it is considered a low complexity evaluation and you will report CPT code 97161.

Below you will find the criteria for a low complexity evaluation. The criteria for moderate and high complexity evaluations will be discussed further in separate articles.

This information is adopted from the APTA quick guide to evaluation codes.

Billing and coding support

Your straight-forward patient with a stable presentation will always be considered a low-complexity evaluation and under CPT code 97161 even if they have more than 2 body systems to address or some relevant comorbidities or personal factors to consider. Still, it is always nice to have a little extra support when it comes to billing.