2025 CPT code 97168
(Active) Effective Date: N/A Revision Date: N/A Rehabilitation - Occupational Therapy Evaluations Medicine/Physical Medicine and Rehabilitation Evaluations Feed
Re-evaluation of an established occupational therapy plan of care due to changes in patient's functional or medical status, resulting in a revised plan of care.
Modifiers may be applicable depending on the circumstances of the service. Consult your payer's guidelines and the CPT manual for appropriate modifier use.
Medical necessity for 97168 is established when a documented change in the patient's condition significantly impacts their ability to participate in activities of daily living or achieve their established therapy goals.The re-evaluation must demonstrate a need for a modification to the existing plan of care.
The occupational therapist is responsible for conducting the re-evaluation, assessing the patient's condition, updating the occupational profile, and developing a revised plan of care.
- Medicine/Physical Medicine and Rehabilitation Evaluations
- Medicine/Physical Medicine and Rehabilitation Evaluations/Occupational Therapy Evaluations
In simple words: The occupational therapist checks in with the patient again because something has changed—maybe the patient is getting better, or facing new challenges. This visit includes a review of what's happening, an update on goals, and a new plan to reach those goals. It usually takes about 30 minutes.
This CPT code, 97168, represents a re-evaluation of an established occupational therapy plan of care.It's indicated when a documented change in the patient's functional or medical status necessitates a reassessment and revision of the existing plan. The reevaluation includes an assessment of these changes, an update to the initial occupational profile reflecting the impact on therapy goals, and the development of a revised plan of care.The face-to-face time with the patient and/or family typically does not exceed 30 minutes.
Example 1: A patient recovering from a stroke experiences a sudden decline in mobility.The occupational therapist performs a re-evaluation (97168) to assess the new limitations and adjust the therapy plan to focus on regaining lost function., A patient with arthritis experiences a flare-up, making previously manageable activities difficult.The therapist uses code 97168 for a re-evaluation to modify the therapy plan, focusing on pain management and adaptive techniques., A patient undergoing rehabilitation after a hip replacement shows significant progress. The occupational therapist uses 97168 for a re-evaluation to advance the patient's goals and transition to higher-level activities.
* Detailed documentation of the patient's current functional status.* A clear explanation of the changes in the patient's condition or environment that necessitate the re-evaluation.* Documentation of the occupational profile update reflecting the changes.* A comprehensive revised plan of care addressing the identified performance deficits.* Time spent face-to-face with the patient and/or family.
** Ensure proper documentation to support medical necessity.The re-evaluation should be distinct from routine progress notes. The re-evaluation must demonstrate a need for a modification to the existing plan of care.Always refer to the most current CPT manual and payer guidelines for billing and coding accuracy.
- Revenue Code: M1B (Office Visits - Established)
- RVU: The RVUs for this code will vary based on geographic location and other factors.Consult your local payer's fee schedule for accurate RVU values.
- Global Days : Not applicable. This is a re-evaluation code, not a global procedure.
- Payment Status: Active
- Modifier TC rule: Not applicable.This is not a procedure with a technical component.
- Fee Schedule : Fee schedules vary by payer and location.Consult your specific payer's fee schedule for historical data.
- Specialties:Occupational Therapy
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Skilled Nursing Facility, other settings as appropriate.