A lot of PT Billing confusion arises when practitioners use the wrong code when filing insurance claims. When is time spent treating patients considered initial evaluation and when is it considered re-evaluation? Aside from the APTA guidelines, we have compiled our most common scenarios and included the codes we used for fast, hassle-free claims approvals.
Here are real-life physical therapy scenarios to help you out:
| Scenario | What code to use |
|---|---|
| Patient is found to be suffering from or to have developed a related condition or a complication resulting from original diagnosis–needing a new care plan. | Re-evaluation (97164) |
| Patient undergoing care or treatment shows unexpected and significant change/(s) in condition, which may mean an unexpected or unanticipated improvement, or sudden decline–needing a re-evaluation of the cause of the change. | Re-evaluation (97164) |
| Patient is unresponsive to original care plan; no improvement or progress is seen as anticipated | Re-evaluation (97164) |
| Patient goes into surgery in the middle of treatment | Initial Evaluation (97161–97163) |
| Patient undergoing care or treatment presents with a condition that is totally unrelated to the primary diagnosis | Initial Evaluation (97161–97163) |
| Patient goes in for post-operation treatment that needs a new plan of care | Initial Evaluation (97161–97163) |
| Patient returns after 60 days of completing care plan and discharge with symptoms similar to initial diagnosis | Initial Evaluation (97161–97163) |
If you encounter unique scenarios that were not included in this basic list, let us know and we’ll be happy to help!
JetPT Billing helps you get paid fast by showing your where your claims reimbursements can be improved. We have clients whose cash flows have improved because of more efficient billing and collection practices.
About JetPT
Jet PT Billing was founded by Kevin Cappel, PT with the desire to provide a much-needed service based on his years of experience and multiple viewpoints relative to the profession of physical therapy and health care, in general. Kevin managed a large corporately-owned outpatient facility for ten years before venturing out into the world of private practice. During his tenure in private practice, he became quite intimate with the area of physical therapy billing and collections and was able to increase their collection per visit statistic from $82/visit to $104/visit while third party reimbursement rates did not increase.
JetPT gives PT Practitioners and Clinicians a risk-free assessment. Call us today at 855-217-5013 or email info@jetptbilling.com.
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