Physical therapy re-evaluation of an established plan of care, including interval history review, standardized tests and measures, and a revised plan of care using measurable functional outcome tools — typically 20 minutes face-to-face.

Verified May 8, 2026 · 8 sources ↓

Medicare: $67.47
Total RVUs: 2.02
Global, days
Region: General

Drawn from CMSBtetechnologiesPabauAAPCWebpt

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 8 cited references ↓

Interval history documenting changes in the patient's condition since the last evaluation or re-evaluation, including new symptoms, functional changes, or barriers to treatment
Objective standardized tests and measures (e.g., range-of-motion measurements, gait speed assessments, functional scales, pain inventories) providing quantifiable evidence of status change
Clinical decision-making rationale explaining why formal reassessment was warranted at this point in care, distinguishing the service from a routine progress note
Revised plan of care reflecting updated goals, modified interventions, or altered treatment frequency and duration based on re-evaluation findings
Identification of the clinical trigger (e.g., failure to progress, new diagnosis, significant functional change) that necessitated the re-evaluation
Face-to-face time with the patient and/or family — typically 20 minutes — documented separately from any same-day treatment time

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

59 Distinct service XS Separate structure

What this code covers

Source · Editorial summary grounded in 8 cited references ↓

97164 is billed when a licensed physical therapist formally reassesses a patient with an established plan of care due to a clinically significant change — not as part of routine progress tracking. Qualifying triggers include new clinical findings, failure to progress toward established goals, a change in diagnosis, or an unexpected functional decline. The re-evaluation must produce a revised plan of care, not just a progress note. Continuous monitoring is bundled into ongoing therapy services and is not separately payable.

Only a licensed PT performs and bills this service. A PTA may assist with data gathering, but the clinical judgment, re-evaluation, and plan revision belong to the PT. When 97164 is billed the same day as treatment codes (e.g., therapeutic exercise), the re-evaluation must be medically necessary, separately identifiable, and documented without conflating re-eval time with treatment time. Modifier 59 is recognized by NCCI for use when 97164 is billed alongside another evaluation service that is separately identifiable on the same date. Modifier 25 does not apply — 97164 is itself an evaluation service, not an E/M add-on.

Medicare Part B claims require modifier GP to route through the correct fiscal intermediary. Prior authorization is not required by Medicare, though MACs conduct post-payment review. Commercial payers vary — some bundle re-evaluations within global therapy authorizations, others require separate approval. Verify payer-specific rules before billing.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	0.96
Practice expense RVU	1.05
Malpractice RVU	0.01
Total RVU	2.02
Medicare national rate	$67.47
Global period	days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$67.47

Common denial reasons

The recurring reasons claims for CPT 97164 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Re-evaluation billed without a documented clinical trigger — routine reassessment or progress tracking is not separately reimbursable
Documentation reads as a progress note rather than a formal re-evaluation with a revised plan of care and updated standardized outcome measures
PTA billed or performed the re-evaluation — only a licensed PT may perform and bill 97164
Modifier GP missing on Medicare Part B claims, causing routing or eligibility denial
Same-day treatment codes bundled without documenting the re-evaluation as a separately identifiable service with distinct time and rationale
Prior authorization absent on commercial plans that require separate approval for re-evaluations outside the global therapy authorization

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 8 cited references ↓

01What's the difference between 97164 and a progress note?

A progress note documents routine ongoing monitoring — it's bundled into therapy services and not separately billable. 97164 requires a specific clinical trigger, formal reassessment using standardized tests, and a revised plan of care. If there's no plan change and no trigger, it's a progress note.

02Can 97164 be billed on the same day as therapeutic exercise or other treatment codes?

Yes, when the re-evaluation is medically necessary and separately identifiable. Document the re-evaluation time distinctly from treatment time, and follow payer-specific bundling and modifier rules. NCCI allows modifier 59 or XS when the services are genuinely distinct.

03Does modifier 25 apply to 97164?

No. Modifier 25 appends to E/M codes to identify a separately identifiable service. 97164 is itself an evaluation service — appending modifier 25 to it is incorrect and will likely be rejected or flagged in audit.

04What modifier is required for Medicare Part B claims?

Modifier GP is required on all Medicare Part B claims for 97164 to route correctly through the fiscal intermediary. Missing GP is a frequent, avoidable denial on Medicare outpatient therapy claims.

05Can a PTA bill or perform 97164?

No. A licensed physical therapist must perform the re-evaluation and sign the documentation. A PTA may gather data under delegation, but the clinical judgment and plan revision must come from the PT. Billing under a PTA is a compliance risk.

06How often can 97164 be billed for the same patient?

There's no fixed frequency limit, but each instance requires a documented clinical trigger. Payers — especially MACs — conduct post-payment review and will flag patterns where re-evaluations occur at regular intervals without documented justification, treating them as routine reassessment.

07Is prior authorization required for 97164?

Medicare does not require prior authorization, though MACs review claims post-payment. Many commercial payers bundle re-evaluations into overall therapy authorizations; others require separate approval. Verify with each payer before billing.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures the clinical trigger from dictation — unexpected plateau, new symptom, functional decline, or goal modification — alongside the standardized outcome measure used and the specific plan-of-care changes made. This prevents the most common 97164 denial: a re-evaluation note that reads as a progress note because it lacks a documented trigger and a revised plan.

See how Mira captures CPT 97164 documentation