CPT® Code 97001

Deleted

Code Deleted: CPT 97001 was deleted effective January 1, 2017. Submitting this code after that date results in claim rejection. Use 97161, 97162, or 97163 for all initial physical therapy evaluations.

Quick Reference

• Code status: Deleted 1/1/2017. The AMA replaced the single undifferentiated PT evaluation code with three complexity-tiered codes (97161, 97162, 97163) and a standalone re-evaluation code (97164). CPT 97002 (PT re-evaluation) was deleted simultaneously.
• Complexity rule: All four required components (history, examination, clinical presentation, clinical decision making) must be documented and must each independently support the selected complexity level. The lowest-level component caps the code.
• Modifier essentials: GP modifier is required on all Medicare outpatient PT evaluation claims. KX is required when billed charges exceed the annual Medicare PT/SLP combined therapy threshold. [1]
• Documentation must-have: A standardized patient assessment instrument (DASH, LEFS, PSFS, OPTIMAL, Oswestry, Berg Balance Scale) must be referenced in the clinical decision-making component; without it, the documentation fails the fourth required element.
• Top confusion point: Some EHR templates and legacy fee schedules still populate 97001. Any claim submitted with 97001 for dates of service on or after January 1, 2017 will be rejected; there is no valid crosswalk that payers apply automatically.
• PTA restriction: Physical therapist assistants cannot perform or bill PT evaluations. Codes 97161 through 97164 are PT-only services; the CQ modifier does not apply to these codes.
• Therapy threshold: Medicare eliminated the hard therapy cap effective January 1, 2018 (Bipartisan Budget Act of 2018). Claims above the annual threshold require the KX modifier to attest ongoing medical necessity; CMS may conduct targeted medical review on above-threshold claims. [2]

When to Use This Code

Historical Context

CPT 97001 applied from 1998 through December 31, 2016, as a single code covering any initial PT evaluation regardless of patient complexity. It required no differentiation by examination scope, number of comorbidities, or clinical decision-making complexity. The AMA restructured PT evaluation coding effective January 1, 2017 to align with the complexity-differentiated framework already used in E/M coding and newly introduced OT evaluation codes (97165 through 97168) [1].

Selecting the Correct Replacement Code

The replacement codes require independent documentation of four components, each of which must meet the threshold for the selected complexity level:

Component 1 — History (comorbidities affecting the plan of care):

• 97161: no personal factors or comorbidities affecting the POC
• 97162: one to two personal factors or comorbidities affecting the POC
• 97163: three or more personal factors or comorbidities affecting the POC

Component 2 — Examination (body system elements assessed using standardized tests/measures):

• 97161: one to two body system elements
• 97162: three or more body system elements
• 97163: four or more body system elements

Component 3 — Clinical presentation:

• 97161: stable and/or uncomplicated
• 97162: evolving or changing
• 97163: unstable and/or unpredictable

Component 4 — Clinical decision making:

• 97161: low complexity
• 97162: moderate complexity
• 97163: high complexity

A patient with three comorbidities (pointing to 97163) whose presentation is stable and examination covers only two body system elements (both pointing to 97161) is correctly coded as 97161. There is no mixing; the lowest level across all four components determines the code.

Provider and Setting Context

PT evaluations are covered in outpatient private practice, hospital outpatient departments, skilled nursing facilities under Part B (not during an SNF Part A stay, where PT is bundled into the SNF PPS rate), and home health under Part B when the patient is not otherwise homebound under a Part A episode. Only a licensed physical therapist, not a PTA, may perform and bill these codes in any setting.

Code Differentiation Table

The most operationally critical differentiator: 97164 is not a substitute for 97161 when the complexity level is unclear. If it is the patient's initial visit, the correct code is one of 97161 through 97163 regardless of how brief or simple the encounter. 97164 applies exclusively to subsequent encounters where a documented functional status change triggers a formal revision of an existing plan of care.

flowchart TD
    A[Initial PT encounter?] -- Yes --> B[Count comorbidities affecting POC]
    A -- No, established POC --> C{Documented change in\nfunctional status + revised POC?}
    C -- Yes --> D[97164 Re-evaluation]
    C -- No --> E[Document in treatment note only\nnot a billable evaluation]
    B --> F[Count body system elements examined]
    F --> G[Characterize clinical presentation]
    G --> H[Assess clinical decision making]
    H --> I{All four components\nat same tier?}
    I -- Low across all four --> J[97161]
    I -- Moderate across all four --> K[97162]
    I -- High across all four --> L[97163]
    I -- Mixed tiers --> M[Use lowest-level tier\nfor the code selection]

Billing & Modifier Rules

GP modifier: Required on all Medicare outpatient PT claims, including evaluations billed with 97161, 97162, 97163, and 97164. Claims submitted without GP will be rejected by Medicare. [3]

KX modifier: Required on Medicare claims when the billed amount crosses the annual combined PT/SLP therapy threshold. The modifier is an attestation that the services are medically necessary and that documentation supports ongoing skilled care. Without KX on above-threshold claims, Medicare denies payment. CMS may initiate targeted medical review on claims where KX is applied. [2]

Modifier 59: May be required when billing an evaluation alongside same-day treatment codes such as 97110 or 97530 if the payer applies a bundling edit. Documentation must show both services were distinct and separately identifiable. Medicare generally allows same-day billing of an initial evaluation and treatment when both are medically necessary; commercial payers vary.

Mutual exclusivity: Only one initial PT evaluation code (97161, 97162, or 97163) may be billed per date of service per discipline. 97164 cannot be billed on the same date as an initial evaluation.

Multiple procedure reduction: The PC/TC Indicator 5 for these codes means that when multiple therapy services are billed on the same date, a 20%/25% reduction applies to the practice expense component of the lower-valued service. This does not prevent billing both an evaluation and treatment on the same day; it governs how the practice expense RVU is calculated.

Time reference: The "typically X minutes" language in the CPT descriptor is a benchmark, not a billing threshold. These codes are billed per encounter, not per unit of time. Billing the correct code does not require that the documented time match any specific threshold.

CQ modifier: Does not apply to evaluations. The CQ modifier (PTA services) is applicable only to treatment codes when a PTA delivers the service. Since evaluations must be performed by a licensed PT, CQ is never appropriate on 97161 through 97164.

Documentation Essentials

For 97161 through 97163, the medical record must explicitly address all four required components [1]:

• History: Chief complaint, history of present illness, and for 97162 the specific comorbidities (named, with explanation of how each affects the plan of care), and for 97163 at least three such comorbidities. A general mention of "hypertension" does not qualify; the note must connect the comorbidity to treatment decision making.
• Examination: The names of specific standardized tests and measures used (goniometry, manual muscle testing, Timed Up-and-Go, Berg Balance Scale, Oswestry Disability Index) and the body system categories they address. Listing test results without identifying the test by name fails this component.
• Clinical presentation characterization: An explicit statement describing whether the presentation is stable, evolving, or unstable/unpredictable. Auditors look for this language verbatim; generic language like "patient presents with pain" does not satisfy this element.
• Clinical decision making: Reference to a standardized patient assessment instrument (DASH, LEFS, PSFS, OPTIMAL, FIM) with the score documented. The instrument must be named and scored, not merely mentioned.
• Plan of care: Short- and long-term functional goals, planned interventions, frequency and duration of treatment, and prognosis. For Medicare, the POC must be certified by the treating physician or NPP within 30 days of the initial evaluation. Missing physician/NPP certification is a post-payment recoupment trigger. [3]

For 97164: The triggering functional change must be explicitly documented (e.g., a fall, new symptom, significant functional decline), updated standardized test scores must appear, and the revised POC must be present with rationale for the changes. A notation that the patient is "progressing" or "not progressing as expected" without revised goals and interventions does not support 97164.

Audit red flags specific to this code range:

• Billing 97163 for every patient in a high-volume practice without corresponding documentation of 3+ comorbidities across all cases
• 97164 billed at routine intervals (e.g., every fourth visit) without a documented triggering event
• Missing standardized assessment instrument name or score in CDM component
• POC without physician/NPP certification signature and date

Medicare, Commercial & Medicaid Payer Rules

Medicare:

CMS covers PT evaluations (97161 through 97164) under the Medicare Part B outpatient therapy benefit when services are medically necessary, require the skill and judgment of a licensed PT, and are provided under a certified plan of care. [3] The annual therapy threshold (PT and SLP combined) is updated annually in the Medicare Physician Fee Schedule final rule; verify the current-year amount through the CMS PFS lookup tool, as the dollar amount changes each year. Above the threshold, the KX modifier is required. CMS may conduct targeted medical review on above-threshold claims. [2]

Functional Reporting using G-codes and severity modifiers was eliminated effective January 1, 2019; do not append those codes to 97161 through 97164. [4]

The CQ modifier differential payment policy, effective January 1, 2020, reduces payment by 15% for units delivered in whole or part by a PTA. This does not apply to evaluations, which are PT-only services. [5]

SNF consolidated billing: During an SNF Part A stay, all PT services including evaluations are bundled into the SNF PPS rate. 97161 through 97164 cannot be billed separately to Part B during a Part A episode.

Prior authorization: CMS has been expanding prior authorization requirements for certain outpatient therapy services in high-utilization geographic areas under the Improving Seniors' Timely Access to Care Act of 2022. [6] Verify whether your MAC's jurisdiction is subject to prior authorization requirements for the evaluation codes.

Commercial payers:

Commercial payer policies vary on same-day billing of evaluations and treatment. Some plans bundle the initial evaluation into the first treatment session and will deny the evaluation when billed alongside a treatment code. Verify plan-specific policies before billing 97162-GP and 97110 on the same date of service for commercial patients; request the payer's therapy billing policy in writing. Modifier 59 on the treatment code may resolve the edit with some commercial payers when accompanied by documentation of distinct services.

Medicaid:

Medicaid therapy billing rules vary by state and managed Medicaid plan. Many state Medicaid programs maintain frequency limitations on PT evaluations (e.g., one evaluation per episode, with prior authorization required for re-evaluation). Verify state-specific rules; the research document does not confirm coverage in specific states.

Common Denials & Prevention

Denial: Invalid procedure code (97001 submitted) Why it happens: Legacy EHR templates, superbills, and some payer crosswalk tables still reference 97001. Submitting this code for any DOS on or after January 1, 2017 generates an immediate rejection. Prevention: Audit charge master and EHR superbill templates annually. Remove 97001 and 97002 from all billable code lists. Confirm that clearinghouse scrubbing rules flag these codes before submission.

Denial: Insufficient documentation to support complexity level Why it happens: Coders select 97163 based on the therapist's clinical impression of complexity, but the medical record does not explicitly address all four components at the high-complexity threshold. Auditors on medical review downcode to 97161 when any single component is underdocumented. Prevention: Implement a pre-billing documentation checklist keyed to the four required components. Each component must be identifiable in the note, not inferred. Train therapists that clinical complexity does not substitute for documented complexity.

Denial: Missing GP modifier Why it happens: Batch billing processes omit the modifier when claims are submitted through clearinghouses that do not auto-append it, or when the claim is manually keyed without modifier entry. Prevention: Set GP as a required default modifier at the charge-capture level for all PT outpatient evaluation and treatment codes. Run a weekly edit report on claims leaving the practice without GP before submission.

Denial: Missing KX modifier above annual threshold Why it happens: Billing staff do not track cumulative therapy charges against the annual threshold in real time, and KX is not appended to claims that cross the threshold. Prevention: Configure the practice management system to trigger a KX alert when cumulative PT/SLP charges for a Medicare patient approach the annual threshold. Document the attestation rationale in the chart before appending KX.

Denial: 97164 denied as not medically necessary (routine re-evaluation) Why it happens: 97164 is billed at scheduled intervals rather than in response to a documented clinical event. Post-payment auditors identify the pattern when re-evaluations appear at uniform intervals across a patient panel. Prevention: Bill 97164 only when the triggering event (functional decline, new injury, significant status change) is documented in the clinical note with updated standardized test scores and a revised POC. Never schedule re-evaluations at fixed intervals as a billing practice.

Coding Scenarios

Scenario 1 — Low complexity, new patient

A 52-year-old with a two-week history of right shoulder pain following a rotator cuff strain presents for initial PT evaluation. No comorbidities affecting the POC. PT examines ROM using goniometry and shoulder strength using manual muscle testing (two body system elements). Clinical presentation is stable. PT administers the DASH questionnaire (score: 34), establishes short- and long-term functional goals, and recommends six visits for rotator cuff strengthening.

Correct coding: 97161-GP (Medicare); 97161 without GP for commercial.

Why: All four components are at the low tier: no comorbidities, two body system elements, stable presentation, low CDM with one standardized instrument. Documenting the DASH score by name and value satisfies the CDM element.

Scenario 2 — High complexity with same-day treatment

A 74-year-old post-CVA patient with Type 2 diabetes, peripheral neuropathy, and heart failure is referred for PT evaluation. PT assesses motor control, sensation, balance, functional transfers, ambulation capacity, and fall risk (six body system elements). Presentation is unstable: daily variation in spasticity and balance. PT administers the Berg Balance Scale (score: 28) and the OPTIMAL tool, documents high-complexity CDM, and establishes the plan of care. Following documentation of the evaluation, PT initiates a 30-minute therapeutic exercise session.

Correct coding: 97163-GP and 97110-GP (2 units); add KX to both if Medicare cumulative threshold has been reached.

Why: All four components independently support the high tier. Both services are documentable as distinct on the same date. For commercial payers that bundle, add modifier 59 on 97110 with supporting documentation.

Scenario 3 — Re-evaluation after clinical event

A patient is three weeks into PT for lumbar radiculopathy when she reports a fall at home with worsening lower extremity symptoms. PT conducts an updated standardized examination using the Oswestry Disability Index (prior score: 28; current score: 48), documents the functional decline and fall as the triggering event, and revises the POC to add balance training and modify frequency from 2x to 3x per week.

Correct coding: 97164-GP (Medicare).

Why: The triggering event (fall, functional decline with documented score change), updated standardized assessment, and revised POC all support 97164. If this were a routine check-in without a documented triggering event, 97164 would not be supportable.

Scenario 4 — Incorrect use of deleted code (compliance example)

A physical therapist in a practice that updated its EHR in 2015 submits claims for a January 2026 initial evaluation using CPT 97001.

Correct coding: The claim will be rejected. The practice must identify the source of the incorrect code (legacy superbill or EHR template), correct the code to 97161, 97162, or 97163 based on documentation, and resubmit within the payer's timely filing window.

Why: CPT 97001 has no valid claim submission pathway for any DOS on or after January 1, 2017. Auditing EHR templates and superbills for deleted codes is a standard compliance responsibility.

Related Codes

• 97161 — PT evaluation, low complexity; primary replacement for 97001 in straightforward cases
• 97162 — PT evaluation, moderate complexity; replacement for 97001 in patients with 1-2 comorbidities and evolving presentations
• 97163 — PT evaluation, high complexity; replacement for 97001 in patients with 3+ comorbidities and unstable presentations
• 97164 — PT re-evaluation; replacement for deleted CPT 97002, subsequent-visit only
• 97110 — Therapeutic exercises, 15-minute units; commonly billed on the same date as the initial evaluation
• 97530 — Therapeutic activities, 15-minute units; commonly paired with evaluations when functional activity training begins at initial visit
• 97140 — Manual therapy techniques, 15-minute units; often initiated on the same date as evaluation
• 97165 — OT evaluation, low complexity; parallel structure to 97161 but for occupational therapy scope

Sources

1. AMA CPT 2017 Code Changes — effective January 1, 2017 — deletion of 97001/97002, introduction of 97161 through 97164 and 97165 through 97168; four required documentation components per complexity level. American Medical Association CPT Editorial Panel, 2016.
2. Bipartisan Budget Act of 2018, P.L. 115-123, Section 50202 — February 9, 2018 — elimination of Medicare therapy hard cap; KX modifier attestation requirement for above-threshold claims; targeted medical review authority.
3. CMS Medicare Claims Processing Manual, Chapter 5 — Part B Outpatient Rehabilitation and CORF/OPT Services — outpatient therapy billing rules including GP/GN/GO modifier requirements, physician/NPP certification of POC within 30 days, and SNF consolidated billing rules.
4. CMS CY2019 OPPS/MPFS Final Rule — November 2018 — elimination of functional reporting G-codes and severity modifiers from therapy claims, effective January 1, 2019.
5. CMS CQ/CO Modifier Implementation — effective January 1, 2020 — PTA/OTA differential payment policy; 15% payment reduction for services delivered in whole or part by a PTA or OTA; does not apply to PT evaluation codes 97161 through 97164.
6. Improving Seniors' Timely Access to Care Act of 2022, P.L. 117-169 — 2022 — CMS prior authorization expansion authority for certain outpatient therapy services.