PT evaluation codes 97161 to 97164

For PT practice owners and billing staff who see children, adults or both: 97161, 97162 and 97163 are the low, moderate and high complexity PT evaluations, leveled on history, examination, clinical presentation and decision making, and 97164 is the re-evaluation. Medicare pays the three levels the same in 2026, so the record, not the fee, decides the level.⁠^1,2

What do the PT evaluation codes 97161 to 97164 describe?

They describe a physical therapist’s initial evaluation at three levels of complexity, low (97161), moderate (97162) and high (97163), and a re-evaluation of an established PT plan of care (97164). The CPT Editorial Panel created them for 2017 to replace the single PT evaluation code 97001 and the re-evaluation code 97002, and CMS adopted them for Medicare that year.⁠^1,9 Because the American Medical Association owns CPT, the descriptions here are this guide’s own; the latest CPT codebook carries the official descriptors, and its physical medicine and rehabilitation subsections hold the official guidelines for PT evaluations.⁠^1,10,11

Everything here is educational. On any claim, the payer’s written rules and the CPT and HCPCS code sets in effect that year are what count, and a coding question about one patient’s claim is for the payer or a certified coding professional to answer.

All four codes are untimed: the claim carries one unit however long the visit runs, and the evaluation’s minutes count toward the note’s total treatment time but never toward the timed-code minutes that set units for treatment codes.⁠^4,11 Each is an always-therapy code that takes the GP modifier when furnished under a PT plan of care, and Medicare’s unit chart allows it only under a PT plan, once per provider, discipline, date of service and patient.⁠^3,11 A physical therapist is limited to a single evaluation or re-evaluation per date of service, and Medicare’s medically unlikely edit for each of the four codes is one unit.⁠^12,13 How an evaluation sits beside timed treatment minutes is worked through in the eight-minute rule guide.

Who may perform the evaluation a PT evaluation code reports?

In a PT practice billing Medicare, the physical therapist: the manual reserves the initial examination, evaluation and re-evaluation for a clinician and bars PTAs from evaluative and assessment services.⁠⁴ The PT may fold in objective measurements or observations a PTA made within the assistant’s scope, but must actively and personally take part in the evaluation and may not simply summarize other people’s findings.⁠⁴ A state practice act can set tighter limits on assistants, so read the state board’s rules as well.

Which four components set the complexity of a PT evaluation?

History, examination, clinical presentation and clinical decision making, which CMS’s 2017 rule called the required components of each code. Summarized in plain words from that rule, the levels look like this:⁠¹

• History: the personal factors and comorbidities that affect the plan of care, none at the low level, one or two at moderate, three or more at high.⁠¹
• Examination: body systems examined with standardized tests and measures, counted as elements drawn from body structures and functions, activity limitations and participation restrictions: one or two at low, three or more at moderate, four or more at high.⁠¹
• Clinical presentation: stable or uncomplicated at low, evolving with features that change at moderate, and unstable, with a course that is hard to predict, at high.⁠¹
• Clinical decision making: low, moderate or high complexity, supported by a standardized assessment instrument or a measurable assessment of functional outcome.⁠¹

The descriptors also carry a typical face-to-face time for each level, 20, 30 and 45 minutes, and CMS said in adopting them that these times are a frame of reference, not a minimum coding requirement.⁠^1,11 A visit that ran long because a family needed an interpreter or help with forms is not more complex for that reason; the four components decide the level. The patient and the service set the level, and neither the fee nor a habit of using one code should.

What if the components point to two different levels?

Choose the level the record supports as a whole, and be ready to show it component by component. A commenter raised exactly this case when the codes were adopted, and CMS answered with the general coding principle: the therapist selects the complexity level that best represents the service furnished and whose medical necessity is clearly documented.⁠¹ Because CMS describes each level’s components as required, a level the record cannot support on every component is hard to defend on review.⁠¹ When the answer is unclear, ask the payer or a certified coder, and keep the answer with its date.

What counts as a personal factor or comorbidity in the history?

A factor counts when it changes the plan of care, which is the distinction CMS asked the profession to explain when the codes took effect.⁠¹ Medicare’s documentation rules point to the complexities that tend to do that: other health services under way for the condition, durable medical equipment needed, the number of medications, a second condition being treated, a mental or cognitive disorder that affects the rate of recovery, and factors such as age, time since onset, stability of symptoms and predictability of progress.⁠⁴ Write each one with its effect, since the manual asks the evaluation to describe how conditions and complexities bear on the prognosis or the plan wherever that is not obvious.⁠⁴ A referral that lists six diagnoses does not give a history of six factors; only the ones that change frequency, progression, precautions or goals count.

How are examination elements counted without double counting?

Count each finding once, under the one category it belongs to. The elements come from body structures and functions, activity limitations and participation restrictions, examined with standardized tests and measures, and CMS asked specifically how therapists choose the number of elements so that nothing is duplicated across the examination of body systems.⁠¹ If hip abductor weakness and the shortened single-leg stance that goes with it are both counted, the note should show that each was measured with its own test and recorded under its own category; a single finding listed under two headings is the duplication CMS asked about. For a PT evaluation, Medicare also wants the body part evaluated named in the record.⁠⁴

Does a higher-complexity PT evaluation pay more under Medicare?

No. In the 2026 Physician Fee Schedule, the national amount is $97.86 for each of 97161, 97162 and 97163 and $67.47 for 97164; the Manhattan locality lists $108.82 for each evaluation and $75.40 for a re-evaluation, and the Arkansas locality $91.20 and $62.36.⁠² Those are the look-up tool’s non-QPP rates for 2026, as updated October 1, 2026, and the facility and non-facility amounts are the same for these codes.⁠² What the patient owes from those amounts is explained in the Medicare therapy coverage guide, and the physical therapy cost guide shows families the same figures.

The equal rate is deliberate. When it adopted the codes for 2017, CMS valued the three complexity levels as a group, at the same work value, saying the approach limits the incentive to code a higher level than was furnished and lets CMS collect data on how the levels are used for possible future rulemaking.⁠¹ Other payers can choose differently: CMS noted that payers other than Medicare may want to pay by complexity, so read each plan’s fee schedule for all three codes.⁠¹

Two Medicare payment rules still reach the evaluation. The four codes appear in CMS’s MPPR rate file for 2026, and Medicare cuts the practice expense portion of each additional always-therapy service furnished that day to 50 percent, paying in full the service whose practice expense value is highest.⁠^14,15 The evaluation also counts as a PT service toward the year’s KX modifier threshold, $2,480 in 2026, a single amount shared by PT and speech-language pathology, above which claims need KX to confirm medical necessity.⁠^3,15

Why does the level matter when the payment is the same?

Because the level is a statement about the patient that the record has to support. Medicare requires the record and the claim to report the services consistently and accurately, with documentation sufficient to justify what was billed.⁠⁴ The complexities named in the evaluation are also what a reviewer reads to judge whether the planned frequency and duration suit that person, since the manual asks the evaluation to make that clear.⁠⁴ A practice that bills one level for every new patient ends up with records that do not describe its patients, and the same habit follows it to the plans that do pay by level.

How do you document each component so the level holds up?

Write each component as a finding with its consequence for the plan, inside the evaluation itself. For Medicare, the evaluation includes a specific diagnosis or condition description with the body part evaluated, all conditions and complexities that may affect treatment, results of a functional measurement, the clinician’s own judgments when they add something the measures do not, and either a finding that treatment is not needed or a prognosis with an expected time frame and a plan of care.⁠⁴ The manual recommends, without requiring, one of four outcome instruments, three of them FOTO’s Patient Inquiry, AM-PAC and OPTIMAL, and lists the information to record when none is used; it tells clinicians to treat APTA’s guidelines as guidelines, not as Medicare policy.⁠⁴

The table puts the four components side by side, with a sentence for each that a note can carry.⁠¹

The plan of care that follows must contain at least the diagnoses, the long-term treatment goals, and the kind of therapy with its amount, its frequency and how long it lasts, and Medicare accepts the evaluation and plan as one document or two.⁠⁴ The outline below keeps the evaluation and the plan in one note.

What does a pediatric PT evaluation need to show at each level?

The same four components, applied to a child’s medical history, development and participation at home, school and play; the codes carry no age criterion, so a child’s evaluation is leveled exactly as an adult’s is.⁠¹ What differs is where the factors come from:

• History: the conditions that change a child’s plan can include a heart condition with exertion limits, a seizure disorder, a feeding tube, a recent orthopedic surgery, or a cognitive or behavioral condition that changes how sessions run; Medicare’s list of complexities, including equipment needed and other services under way, works as a checklist for children too.⁠⁴
• Examination: standardized measures for a child can include a norm-referenced motor development test, a balance or gait measure, range of motion and strength, and a participation measure from the parent; record each by name, edition and score so the element count can be checked.
• Presentation: a child whose skills are slipping, whose medical status changes week to week, or who has just come home from the hospital presents differently from a child with a long-standing, steady condition, and the note should say which it is and why.

Children under 21 in Medicaid are entitled under EPSDT to any service federal Medicaid law can cover that is found medically necessary to treat or improve a condition, even a service the state plan leaves out, and each state decides medical necessity for each child individually.⁠⁷ States must also post their fee-for-service rates publicly, organized so anyone can find the amount for a service and showing pediatric and adult rates apart when they differ; the first posting was due by July 1, 2026.⁠⁸ Before a first visit, look up 97161 to 97164 on that schedule: are the three levels priced the same, does the evaluation need prior approval, and what modifiers does the state’s billing manual want? A child’s managed care plan answers the same questions in its provider manual, and the EPSDT guide sets out what the program owes children.

One edit matters more for children. Developmental testing codes 96112 and 96113 are the column one codes over every PT evaluation and re-evaluation code, with a modifier allowed, so a developmental test and a PT evaluation on one date need separate, documented services.⁠⁶ School evaluations under an IEP and early intervention evaluations follow their own programs’ rules and sit outside this guide; for how an outpatient practice works alongside them, see working with IEP teams and infant development programs, and for growing a pediatric caseload, the pediatric PT patients guide.

What does an adult PT evaluation need to show at each level?

The same components, with the adult’s medical picture usually driving the history and the presentation. Under Medicare Part B, the evaluation leads to a plan of care that a physician, nurse practitioner, clinical nurse specialist or physician assistant certifies, and the initial certification is on time when dated within 30 days, counting from the first treatment day, and the evaluation counts as treatment for that purpose.⁠^4,5 Three common adult pictures show how the components play out:

• Falls: CDC’s STEADI toolkit lists the 30-Second Chair Stand Test, the 4-Stage Balance Test, the Timed Up and Go test and orthostatic blood pressure among its assessments for older adults’ fall risk; results like these are standardized examination elements, and the medications, devices and other conditions behind the falls count in the history when they change the plan.⁠^4,16
• After surgery: a joint replacement with no other condition that changes the plan and an uneventful recovery may support a lower level, while the same surgery with a wound problem, diabetes that changes progression and a course that keeps shifting may support a higher one; the record decides, not the procedure.
• Neurologic conditions: after a stroke, or with Parkinson disease or multiple sclerosis, the presentation can be evolving or unstable and the examination can span several categories; record which elements were tested and which features of the presentation changed, and when.

Medicare’s own list of complexities, such as the number of medications, durable medical equipment and other services under way, fits adult cases closely, and recording them is how a reviewer sees why the plan is what it is.⁠⁴ Coverage questions patients ask, such as certification and treatment to maintain function, are answered in the Medicare therapy coverage guide, and the adult PT patients guide covers building an adult caseload.

When does Medicare cover a PT re-evaluation billed as 97164?

When the patient shows new clinical findings, has changed significantly, or has not responded to the planned treatment, so that further tests and measurements are needed; Medicare pays for a formal re-evaluation only if the record supports that need.⁠⁴ The manual says plainly that a re-evaluation is not a routine, recurring service, and that the continuous assessment of progress that is part of every treatment visit is not payable as one.⁠⁴ A re-evaluation may also be appropriate before a planned discharge, to decide whether the goals have been met.⁠⁴

The definition adds that the change must be one the plan of care did not anticipate, and that where a state practice act requires re-evaluation at set times, Medicare payment still needs the re-evaluation to meet Medicare’s coverage rules.⁠^1,4 On the claim side, NCCI says re-evaluation is not reported routinely during a planned course of therapy; when the patient’s status changes and a re-evaluation is medically necessary, 97164 takes modifier 59 or XU beside the treatment codes it is edited against.⁠¹² In the file effective October 1, 2026, 97164 is the column two code, with a modifier allowed, beside traction, electrical stimulation, ultrasound and other modalities, massage, 97533, 97535, 97542, wound care codes, and 97760 and 97761, while its rows with 97110, 97112, 97116, 97140 and 97530 are no longer live.⁠⁶

A re-evaluation needs the same professional skills as the evaluation, and its minutes are documented the same way, as untimed minutes inside total treatment time.⁠⁴ It is usually narrower than the first evaluation, focused on the current treatment.⁠⁴

Is a plan-of-care recertification the same as a re-evaluation?

No. Recertification is the physician’s or practitioner’s renewed approval of the plan, required at least every 90 days, with the plan or record showing a continuing need for therapy and the reviewer signing the medical record.⁠⁵ Medicare’s manual adds that a recertification should be signed when the need for a significant change to the plan becomes evident, and that recertification dates do not shift the progress report, which must come at least every 10 treatment days.⁠⁴ None of those events is a reason to bill 97164 on its own; a re-evaluation is billed when the patient’s status calls for new tests and measures, whatever the calendar says.⁠⁴

For the initial certification, the regulation excuses the physician’s or practitioner’s signature on a therapist’s plan when a written order or referral from that clinician is in the chart and the therapist can show the plan was sent to that clinician no more than 30 days after the initial evaluation was completed.⁠⁵ The regulation also states that its mentions of an order or referral do not make either one a condition of outpatient PT.⁠⁵ APTA reports that every state, the District of Columbia and the U.S. Virgin Islands let patients see a PT for evaluation and treatment without a referral, in either a provisional or an unrestricted form, as of July 1, 2025, with some states keeping conditions on treatment without one.⁠¹⁷ Whether a plan requires a referral is a separate question to put to each payer; the PT practice start-up guide covers both.

Can a PT bill an evaluation and treatment on the same day?

Yes. Under Medicare’s manual, an evaluation and treatment can each be billed on the same day or at a later visit, and the current edit file has no live pair between the PT evaluation codes and therapeutic exercise (97110), neuromuscular reeducation (97112), gait training (97116), manual therapy (97140) or therapeutic activities (97530).⁠^4,6 The treatment’s minutes still have to be separate from the evaluation’s: evaluation time is not billed again as treatment time, and timed-code minutes leave it out.⁠⁴ NCCI also forbids reporting two physical medicine services for one 15-minute period (supervised modalities excepted) and expects accurate coding whether or not an edit exists.⁠¹²

Pairs below come from version 323r0 of the practitioner edits, effective October 1, 2026 and posted September 2, 2026.⁠⁶

Several pairs that used to be edits are dead rows in the same file: the rows pairing the three evaluations with 97140, 97530 or group code 97150 have deletion dates equal to their effective dates in 2020, and the rows pairing 97164 with 97110, 97112, 97116, 97140, 97150 and 97530 ended December 31, 2019, their later rows carrying a deletion date equal to their effective date of October 1, 2020.⁠^6,18 CMS posts changes to the edit files every quarter, so check these pairs against each new quarter’s file.⁠⁶

When a PT and an OT each evaluate the patient on the same date, both evaluations may be reported, because the one-evaluation limit applies per practitioner.⁠¹² Chapter 11 likewise lets a practice report 97750, 97755 or 97763 beside a PT evaluation, with an NCCI-associated modifier, only when a practitioner of a different specialty, such as an OT, furnished it; when a second PT furnished it, the two are not separately reportable.⁠¹² Treatment codes that PT and OT have in common are laid out in the OT procedure codes guide.

When may modifier 59 or XU go on a code paired with an evaluation?

Only when the record shows a distinct service on a pair whose edit allows a modifier. NCCI’s general rules forbid adding a modifier just to get past an edit, require the chart to satisfy whatever criteria the chosen modifier carries, reject a different diagnosis alone as grounds for 59, and let no modifier override an edit whose indicator is 0.⁠¹⁸ For physical medicine codes, chapter 11 accepts 59 or XU when the two services occupied different time intervals, including back-to-back intervals in one encounter.⁠¹² Beside an evaluation, that means the note shows the evaluation’s minutes and the other service’s minutes as separate blocks and says why the second service was needed that day.

How do commercial plans and Medicaid handle PT evaluation levels?

By their own policies, which can differ from Medicare’s on payment by level, authorization, re-evaluation frequency and modifiers. APTA reminds PTs that CPT coding is not payment policy, which each payer and benefit plan sets, and CMS noted when adopting these codes that payers other than Medicare may want to pay differently by complexity.⁠^1,10

File every answer under the plan’s name with the date and its source, whether a person or a document, and look again whenever the plan issues a new policy. For families paying privately, give the evaluation price and what it includes before the first visit; the insurance and fees guide covers how to say it.

Which mistakes put a PT evaluation level at risk?

The ones that let something other than the patient pick the level. Each item below is a rule the sources state, turned into what goes wrong.

• Leveling by the clock. The typical times are a frame of reference and not a minimum requirement, so a long visit does not make an evaluation complex and a short one does not make it simple.⁠¹
• Counting factors that do not change the plan. The history counts personal factors and comorbidities that affect the plan of care, not every diagnosis on the referral.⁠¹
• Counting one finding twice. CMS asked specifically how therapists keep from duplicating elements across the examination.⁠¹
• A default level. Billing one level for every new patient ignores CMS’s instruction to choose the level that best represents the service furnished.⁠¹
• Billing 97164 for progress checks. Continuous assessment is not a payable re-evaluation, and NCCI says re-evaluation is not reported routinely during a planned course.⁠^4,12
• Re-evaluating because a recertification is due. Recertification is the practitioner’s review of the plan at least every 90 days, not a reason for new tests.⁠^4,5
• Adding evaluation minutes to timed minutes. Evaluation minutes count in total treatment time only.⁠⁴
• Billing a performance test beside the evaluation. A same-day 97750, 97755 or 97763 from the evaluating therapist cannot go on the claim with 97161 to 97164, and no modifier changes that.⁠^6,12
• Letting an assistant carry the evaluation. A PTA may contribute measurements within scope, but the PT performs the evaluation and takes part personally.⁠⁴

How are a child’s and an adult’s PT evaluations leveled in practice?

Each evaluation is leveled component by component from the record, then checked against the payer and the current edits. The two cases below are invented; the payer rules in them are assumptions for the example, not descriptions of any real plan.

Sources

1. Federal Register (Centers for Medicare & Medicaid Services). Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017 (final rule, 81 FR 80170, published November 15, 2016, effective January 1, 2017, document 2016-26668, Government Publishing Office text; the section on evaluative procedures for physical therapy and occupational therapy, pages 80331 to 80338). Checked October 25, 2026.
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   “For CY 2017, the CPT Editorial Panel deleted four CPT codes (97001, 97002, 97003, and 97004) and created eight new CPT codes (97161-97168)”; “There are three new codes, stratified by complexity, to replace a single CPT code 97001, for physical therapy (PT) evaluation”; “one new code each to replace the re-evaluation codes for physical and occupational therapy, CPT codes 97002 and 97004.”; “we are finalizing our proposal to adopt new CPT codes 97161-97168 for PT and OT evaluations and re-evaluations.”; “Table 23 includes the long descriptors and the required components of each of the eight new CPT codes for the PT and OT services.”; “For the PT codes, we sought more information about how the physical therapist differentiates the number of personal factors that actually affect the plan of care.”; “We were also interested in understanding more about how the physical therapist selects the number of elements from any of the body structures and functions, activity limitations, and participation restrictions to make sure there is no duplication during the physical therapist’s examination of body systems.”; “are included as a frame of reference and do not represent a minimum coding requirement.”; “the typical times in the new PT and OT CPT codes represent the typical face-to-face time of the physical or occupational therapist with the patient.”; “One commenter noted that an evaluation may have characteristics that fall between two complexity levels”; “the therapist should select the evaluation complexity level that best represents the furnished service and for which the medical necessity is clearly documented.”; “the CPT manual PM&R subsections for PT and OT Evaluations contain official CPT guidelines.”; “we are finalizing our proposal to use the PAMA authority to value services as groups rather than individually”; “valuing each complexity level at 1.2 work RVUs for the PT and OT family of evaluation codes for CY 2017.”; “It limits the incentives for and consequences of upcoding by therapists and providers”; “allowing us to collect and analyze utilization data of the complexity levels for possible future rulemaking.”; “other payers may have direct interest in making such differential payment based on complexity of OT and PT evaluation.”; “requires a significant change in the patient’s condition or functional status that was not anticipated in the plan of care.”; “This means that they always represent therapy services regardless of who performs them and always require a therapy modifier, GP or GO, to signify that the services are furnished under a PT or OT plan of care, respectively.”. Summarized in plain words, not quoted, because Table 23 reprints the CPT descriptors (copyright American Medical Association): for 97161, 97162 and 97163 in turn, a history with none, one or two, or three or more personal factors or comorbidities that affect the plan of care; an examination using standardized tests and measures that covers one or two, three or more, or four or more elements drawn from body structures and functions, activity limitations and participation restrictions; a clinical presentation that is stable, evolving or unstable; clinical decision making of low, moderate or high complexity using a standardized assessment instrument or a measurable assessment of functional outcome; and typical face-to-face times of 20, 30 and 45 minutes; for 97164, an examination that reviews the history and uses standardized tests and measures, a revised plan of care, and a typical face-to-face time of 20 minutes.
2. Centers for Medicare & Medicaid Services. Search the Physician Fee Schedule (PFS Look-up Tool, year 2026, Non-QPP Rates, Pricing Information; the tool reads “Data Updated: 10/01/2026”). Checked October 25, 2026.
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   “Use this search to view adjusted pricing amounts that reflect variations in pricing costs from area to area.”; non-facility price for the National Payment Amount (locality 0000000), Manhattan (locality 1320201) and Arkansas (locality 0710213), in that order: 97161, $97.86, $108.82, $91.20; 97162, $97.86, $108.82, $91.20; 97163, $97.86, $108.82, $91.20; 97164, $67.47, $75.40, $62.36; the facility price equals the non-facility price for each code in each locality; conversion factor 33.4009; the tool’s short descriptions for 97161, 97162 and 97163 carry 20, 30 and 45 minutes.
3. Centers for Medicare & Medicaid Services. Annual Therapy Update (page last modified March 4, 2026, with its 2026 Therapy Code List and Dispositions workbook, CY_2026_Therapy_Code_List_and_Dispositions_v3). Checked October 25, 2026.
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   “The files on this web page contain the list of codes indicating whether they are sometimes or always therapy services.”; disposition 5: “These codes are “always therapy” services, regardless of who performs them.”; disposition 9: “require a specific therapy modifier − GP, GO, or GN − to indicate when the evaluative service is furnished under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively.”; in the workbook, 97161, 97162, 97163 and 97164 each carry disposition 5 and disposition 9 with GP, effective January 1, 2017.
4. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220 definitions, §§220.1.2, 220.1.3, 220.3 and 230.1). Checked October 25, 2026.
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   “EVALUATION is a separately payable comprehensive service provided by a clinician, as defined above, that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities.”; “Evaluation is warranted e.g., for a new diagnosis or when a condition is treated in a new setting.”; “Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, or decline, or change in the patient’s condition or functional status that was not anticipated in the plan of care.”; “Although some state regulations and state practice acts require re-evaluation at specific times, for Medicare payment, reevaluations must also meet Medicare coverage guidelines.”; “The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits.”; “Diagnoses;”; “Long term treatment goals; and”; “Type, amount, duration and frequency of therapy services.”; “The initial treatment includes the evaluation that resulted in the plan.”; “Timely certification of the initial plan is met when physician/NPP certification of the plan is documented, by signature or verbal order, and dated in the 30 days following the first day of treatment (including evaluation).”; “Recertifications that document the need for continued or modified therapy should be signed whenever the need for a significant modification of the plan becomes evident, or at least every 90 days after initiation of treatment under that plan, unless they are delayed.”; “To be payable, the medical record and the information on the claim form must consistently and accurately report covered therapy services, as documented in the medical record.”; “Documentation must be legible, relevant and sufficient to justify the services billed.”; “Utilize the guidelines of the American Physical Therapy Association, the American Occupational Therapy Association, or the American Speech-Language and Hearing Association as guidelines, and not as policy.”; “Only a clinician may perform an initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a plan of care.”; “A clinician may include, as part of the evaluation or re-evaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evaluation or re-evaluation.”; “The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.”; “Documentation of the evaluation should list the conditions and complexities and, where it is not obvious, describe the impact of the conditions and complexities on the prognosis and/or the plan for treatment such that it is clear to the contractor who may review the record that the services planned are appropriate for the individual.”; “A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated.”; “For PT and OT, be sure to include body part evaluated.”; “Include all conditions and complexities that may impact the treatment.”; “Results of one of the following four measurement instruments are recommended, but not required:”; “Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)”; “Activity Measure – Post Acute Care (AM-PAC)”; “OPTIMAL by Cedaron through the American Physical Therapy Association”; “Identification of durable medical equipment needed for this condition”; “Identification of the number of medications the beneficiary is taking (and type if known)”; “Identification of factors that impact severity including e.g., age, time since onset, cause of the condition, stability of symptoms, how typical/atypical are the symptoms of the diagnosed condition, availability of an intervention/treatment known to be effective, predictability of progress.”; “Identification of whether beneficiary was treated for this same condition previously by the same therapy discipline”; “A determination that treatment is not needed, or, if treatment is needed a prognosis for return to premorbid condition or maximum expected condition with expected time frame and a plan of care.”; “the evaluation serves as the plan of care if it contains a diagnosis, or in states where a therapist may not diagnose, a description of the condition from which a diagnosis may be determined by the referring physician/NPP.”; “when evaluation is the only service, a referral/order and evaluation are the only required documentation.”; “If the patient presented for evaluation without a referral or order and does not require treatment, a physician referral/order or certification of the evaluation is required for payment of the evaluation.”; “The time spent in evaluation shall not also be billed as treatment time.”; “Evaluation minutes are untimed and are part of the total treatment minutes, but minutes of evaluation shall not be included in the minutes for timed codes reported in the treatment notes.”; “Re-evaluations are usually focused on the current treatment and might not be as extensive as initial evaluations.”; “Continuous assessment of the patient’s progress is a component of ongoing therapy services and is not payable as a re-evaluation.”; “A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services.”; “A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation.”; “Indications for a re-evaluation include new clinical findings, a significant change in the patient’s condition, or failure to respond to the therapeutic interventions outlined in the plan of care.”; “A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met”; “Reevaluation requires the same professional skills as evaluation.”; “The minutes for re-evaluation are documented in the same manner as the minutes for evaluation.”; “The minimum progress report period shall be at least once every 10 treatment days.”; “It should be emphasized that the dates for recertification of plans of care do not affect the dates for required progress reports.”; “The evaluation and plan may be reported in two separate documents or a single combined document.”; “Identification of other health services concurrently being provided for this condition”; “The beneficiary has, in addition to the primary condition being treated, another disease or condition being treated”; “The beneficiary has a mental or cognitive disorder in addition to the condition being treated”; “Clinician’s clinical judgments or subjective impressions that describe the current functional status of the condition being evaluated, when they provide further information to supplement measurement tools”; “PTAs may not provide evaluative or assessment services, make clinical judgments or decisions; develop, manage, or furnish skilled maintenance program services; or take responsibility for the service.”.
5. Code of Federal Regulations. 42 CFR 424.24, Requirements for medical and other health services furnished by providers under Medicare Part B (eCFR, up to date as of October 22, 2026; paragraph (c), outpatient physical therapy, occupational therapy and speech-language pathology services). Checked October 25, 2026.
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   “The services were furnished while the individual was under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant.”; “The initial certification must be obtained as soon as possible after the plan is established.”; “the certification must be signed by a physician or by a nurse practitioner, clinical nurse specialist, or physician assistant who has knowledge of the case, except as specified in paragraph (c)(5) of this section.”; “Recertification is required at least every 90 days.”; “When it is recertified, the plan or other documentation in the patient’s record must indicate the continuing need for physical therapy, occupational therapy or speech-language pathology services.”; “The physician, nurse practitioner, clinical nurse specialist, or physician assistant who reviews the plan must recertify the plan by signing the medical record.”; “the therapist has documented evidence that the plan of treatment has been delivered to the physician, NP, PA, or CNS within 30 days of completion of the initial evaluation, the certification does not need to be signed by a physician, NP, CNS, or PA who has knowledge of the case.”; “No references to an order or referral in this subsection shall be construed to require an order or referral for outpatient physical therapy, occupational therapy, or speech-language pathology services.”.
6. Centers for Medicare & Medicaid Services. Medicare NCCI Procedure to Procedure (PTP) Edits (page last modified September 1, 2026; 2026 Quarter 4 practitioner files, version 323r0, all four parts). Checked October 25, 2026.
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   “If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied unless a clinically appropriate NCCI PTP-associated modifier is also reported.”; “CMS posts changes to each of its NCCI PTP published edit files on a quarterly basis.”; “Practitioner PTP Edits v323r0 (612,539 Records) 62292/01912 -- U0003/U0004 - Effective Oct. 1, 2026; Posted September 2, 2026”. In the four version 323r0 practitioner files (column one/column two, then the modifier indicator, where 0 is not allowed, 1 is allowed and 9 marks a pair whose deletion date equals its effective date): each of 97161, 97162, 97163 and 97164 with 97750, 97755, 97763, 95851 and 95852, indicator 0; 97162/97161, 97163/97161 and 97163/97162, indicator 0; each of 97161, 97162 and 97163 with 97164, indicator 0; each of 97161 to 97164 with 96105, 96125, 96130, 96132, 96136, 96138 and 96146, indicator 1; 96112 and 96113 each with 97161, 97162, 97163 and 97164, indicator 1; 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97124, 97129, 97130, 97139, 97533, 97535, 97537, 97542, 97545, 97597, 97598, 97602, 97605, 97606, 97607, 97608, 97760, 97761, G0281, G0283 and G0329 each with 97164, indicator 1; the rows pairing 97161, 97162 and 97163 with 97140 carry deletion dates equal to their effective dates, January 1, 2020 and October 1, 2020; the rows pairing 97530 and 97150 with 97161, 97162 and 97163 carry a deletion date equal to their effective date, January 1, 2020; the rows pairing 97110, 97112, 97116, 97140, 97150 and 97530 with 97164 carry a deletion date of December 31, 2019, and their later rows a deletion date equal to their effective date, October 1, 2020; no row pairs 97110, 97112 or 97116 with 97161, 97162 or 97163.
7. Medicaid.gov (Centers for Medicare & Medicaid Services). Early and Periodic Screening, Diagnostic, and Treatment. Checked October 25, 2026.
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   “The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.”; “States are required to provide any additional 1905(a) services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan.”; “It is the responsibility of states to determine medical necessity on a case-by-case basis.”.
8. Code of Federal Regulations. 42 CFR 447.203, Documentation of access to care and service payment rates (Medicaid; eCFR, up to date as of October 22, 2026; paragraph (b)(1)). Checked October 25, 2026.
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   “The State agency is required to publish all Medicaid fee-for-service fee schedule payment rates on a website that is accessible to the general public.”; “Medicaid fee-for-service payment rates must be organized in such a way that a member of the public can readily determine the amount that Medicaid would pay for a given service.”; “If the rates vary, the State must separately identify the Medicaid fee-for-service payment rates by population (pediatric and adult), provider type, and geographical location, as applicable.”; “The initial publication of the Medicaid fee-for-service payment rates shall occur no later than July 1, 2026”.
9. American Physical Therapy Association. Tiered Physical Therapy Evaluation and Reevaluation CPT Codes (Coding and Billing; public summary, with the quick guide for members). Checked October 25, 2026.
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   “The two familiar CPT codes for physical therapy evaluation and reevaluation disappeared in January 2017.”; “The new evaluation codes reflect three levels of patient presentation: low-complexity (97161), moderate-complexity (97162), and high-complexity (97163), and replace the 97001 code.”; “The new reevaluation code (97164) replaces 97002.”.
10. American Physical Therapy Association. Coding for Interventions (Current Procedural Terminology Codes) (Coding and Billing). Checked October 25, 2026.
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    “PTs can bill any code if furnishing that service is permitted under state licensure laws and payer policy.”; “Keep in mind that CPT coding is not the same as payment policy.”; “Payment policy is determined by each payer and/or by employer benefit package language.”; “CPT® is a registered trademark of the American Medical Association, and all CPT codes and descriptions are copyrighted by AMA”.
11. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and CORF/OPT Services (Pub. 100-04, Rev. 11129; §§20 and 20.2). Checked October 25, 2026.
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    “Therapy modifiers are GP for physical therapy, GO for occupational therapy, and GN for speech-language pathology.”; “The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered:”; “GP Services delivered under an outpatient physical therapy plan of care.”; “When reporting service units for HCPCS codes where the procedure is not defined by a specific timeframe (“untimed” HCPCS), the provider enters “1” in the field labeled units.”; “For any single timed CPT code in the same day measured in 15 minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes.”; “The codes that are allowed one unit for “Allowed Units” in the chart below may be billed no more than once per provider, per discipline, per date of service, per patient.”; “The codes allowed 0 units in the column for “Allowed Units”, may not be billed under a plan of care indicated by the discipline in that column.”; “We note that the official long descriptors for the CPT codes can be found in the latest CPT code book.”; the §20.2 chart gives 97161, 97162, 97163 and 97164 one allowed unit under a PT plan of care and none under an OT or speech-language pathology plan, and its consumer-friendly descriptions give typical times of 20, 30 and 45 minutes for the three evaluations and 20 minutes for the re-evaluation.
12. Centers for Medicare & Medicaid Services. NCCI Policy Manual for Medicare Services, Chapter XI, Medicine and Evaluation and Management Services (effective January 1, 2026; revision date 1/1/2026; sections P and V). Checked October 25, 2026.
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    “Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2025 American Medical Association. All rights reserved.”; “A physical therapist may report only one evaluation/re-evaluation (CPT codes 97161-97164) on a single date of service.”; “A physician or facility shall not report both an occupational therapy evaluation/re-evaluation service and physical therapy evaluation/re-evaluation service if performed by the same practitioner.”; “If the 2 services are performed by 2 different practitioners on the same date of service, both procedures may be reported.”; “With one exception, providers/suppliers shall not report more than one physical medicine and rehabilitation therapy service for the same fifteen-minute time period.”; “The only exception involves a “supervised modality” defined by CPT codes 97010-97028, which may be reported for the same fifteen-minute time period as other therapy services.”; “These edits may be bypassed with modifier 59 or XU if the 2 procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter.”; “Physicians are expected to code correctly even in the absence of NCCI PTP edits.”; “The NCCI program contains PTP edits with Column One codes of the physical medicine and rehabilitation therapy services and Column Two codes of the physical therapy and occupational therapy re-evaluation CPT codes of 97164 and 97168 respectively.”; “The re-evaluation services shall not be routinely reported during a planned course of physical or occupational therapy.”; “if the patient’s status should change and a re-evaluation is medically reasonable and necessary, it may be reported with modifier 59 or XU appended to CPT code 97164 or 97168 as appropriate.”; “are not separately reportable for the same date of service with a physical therapy evaluation/re-evaluation CPT code (e.g., 97161-97164) or occupational therapy evaluation/re-evaluation CPT code (e.g., 97165-97168) when the 2 services are performed by a single practitioner or 2 practitioners of the same specialty.”; “For example, if a physical therapist performs 1 service and an occupational therapist performs the other service, the 2 services may be reported separately.”; “If the 2 services are performed by 2 different practitioners of different specialties, the 2 services may be reported using an NCCI PTP-associated modifier.”; “However, if a physical therapist performs 1 service and a different physical therapist performs the other service, the 2 services are not separately reportable.”; “Physical therapy evaluation (CPT codes 97161-97163) and occupational therapy evaluation (CPT codes 97165-97167) shall not be reported with more than one unit of service per episode of care.”; “Physical therapy re-evaluation (CPT code 97164) and occupational therapy re-evaluation (CPT code 97168) shall not be reported with more than one unit of service per date of service.”; section P.8 names 97750, 97755 and 97763 as the codes in the passage on evaluations.
13. Centers for Medicare & Medicaid Services. Medicare NCCI Medically Unlikely Edits (MUEs) (page last modified August 31, 2026, with the Practitioner Services MUE Table effective October 1, 2026). Checked October 25, 2026.
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    “An MUE is the maximum units of service (UOS) reported for a HCPCS/CPT code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service.”; the table gives 97161, 97162, 97163 and 97164 each a value of 1, with the adjudication indicator “2 Date of Service Edit: Policy”.
14. Centers for Medicare & Medicaid Services. MPPR Rate File 2026 (updated February 24, 2026; linked from the Therapy Services page). The 2026 file, headed “Multiple Procedure Payment Reduction Rate File for 2026”, lists 97161, 97162, 97163 and 97164 among its codes, each with a fee amount and a reduced amount by carrier and locality. Checked October 25, 2026.
15. Centers for Medicare & Medicaid Services. Therapy Services (page last modified March 10, 2026). Checked October 25, 2026.
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    “Just as with the incurred expenses for the therapy cap amounts, there is one amount for PT and SLP services combined and a separate amount for OT services.”; “the law preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.”; “Claims for services over the KX modifier threshold amounts without the KX modifier are denied.”; “For CY 2026 this KX modifier threshold amount is:”; “$2,480 for PT and SLP services combined, and”; “Medicare applies a MPPR to the practice expense component of certain “always therapy” services.”; “It applies to the second and subsequent therapy services provided to a patient on the same day.”; “The service with the highest PE relative value unit (RVU) is paid at 100% and the remaining services are paid at 50%.”; section 6209 of the Consolidated Appropriations Act, 2026 “extended the ability of PTs, OTs, and SLPs to furnish Telehealth Services” “through December 31, 2027”.
16. Centers for Disease Control and Prevention. STEADI: Clinical Resources (STEADI, Older Adult Fall Prevention). “Find a collection of materials to help healthcare providers screen, assess, and intervene to reduce fall risk among their older patients.”; under “Functional assessments”: “30-Second Chair Stand Test”; “4-Stage Balance Test”; “Timed Up and Go (TUG) Test”; “Measuring Orthostatic Blood Pressure”. Checked October 25, 2026.
17. American Physical Therapy Association. Direct Access Advocacy (Advocacy Issues). Checked October 25, 2026.
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    “As of July 1, 2025, all 50 states, the District of Columbia, and the U.S. Virgin Islands have either provisional or unrestricted direct access to physical therapist services for evaluation and treatment.”; “Even though patients may go directly to a physical therapist without a referral, some provisions tied to treatment absent a referral still persist in a number of states”.
18. Centers for Medicare & Medicaid Services. NCCI Policy Manual for Medicare Services, Chapter I, General Correct Coding Policies (effective January 1, 2026; revision date 1/1/2026; section E, Modifiers and Modifier Indicators). Checked October 25, 2026.
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    “A modifier shall not be appended to a HCPCS/CPT code solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use.”; “A CCMI of “0” indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit”; “A CCMI of “1” indicates that NCCI PTP-associated modifiers may be used to bypass an edit under appropriate circumstances.”; “This indicator is used for all code pairs that have a deletion date that is the same as the effective date.”; “Documentation in the medical record must satisfy the criteria required by any NCCI PTP-associated modifier used.”; “If 2 separate and distinct timed services are provided in separate and distinct time blocks, modifier 59 may be used to identify the services.”; “Additionally, different diagnoses are not adequate criteria for use of modifiers 59 or XE or XS.”.
19. Centers for Medicare & Medicaid Services. List of Telehealth Services (page last modified March 4, 2026, with the List of Telehealth Services for Calendar Year 2026 file). “List of services payable under the Medicare Physician Fee Schedule when furnished via telehealth.”; the CY 2026 final list carries 97161, 97162, 97163 and 97164, each marked “Maintain”. Checked October 25, 2026.
20. DrSensory. DrSensory for therapists (the For Therapists hub). Checked October 25, 2026.
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    “DrSensory is a directory families use free to find occupational therapy, physical therapy and speech therapy clinics”; “Every clinic keeps a basic listing at no cost.”; “The directory lists clinics rather than individual therapists, so one listing covers a whole practice at one address.”; “It does not mean DrSensory checked its clinical work.”.
21. DrSensory. Therapy Clinic Directory Pricing. “Families never pay to search or to contact you.”; the comparison of free and paid listings marks “Ages and conditions treated” and “A description in your own words” as part of a paid listing; “We do not verify clinical quality.”. Checked October 25, 2026.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. CPT codes and their descriptors belong to the American Medical Association; the descriptions here are plain-language summaries, not the official text.