CPT Code 97168: Occupational Therapy Re-Evaluation

What is occupational therapy re-evaluation?

CPT code 97168 refers to a formal occupational therapy re-evaluation used when there is a documented change in the patient's condition, functional status, medical status, or clinical findings. Unlike the initial evaluation, this re-evaluation focuses on assessing ongoing therapy services, revising the established plan of care, and determining future interventions based on measurable assessment tools and clinical judgment.

It's typically performed by an occupational therapist when new clinical findings, a lack of significant improvement, or a significant change in functional performance requires an updated therapy evaluation to guide effective treatment planning and ensure appropriate reimbursement.

Documentation requirements

For the 97168 CPT code, documentation must support the medical necessity of a formal re-evaluation and reflect the clinical judgment behind revisiting the occupational therapy established plan. Include the following elements:

• Reason for re-evaluation: This may include a change in medical services status, new clinical findings, a plateau in progress, or a need to revise the treatment plan.
• Summary of prior evaluation and progress: Reference the initial evaluation, ongoing therapy services, and the patient’s progress toward previously established treatment goals.
• Updated measurable assessments: Provide objective data such as range of motion (ROM), activities of daily living (ADL) performance, cognitive function, and other relevant standardized tests.
• Revised plan of care: Justify updates to therapy evaluation, new functional goals, and planned therapeutic exercises and interventions to improve functional outcome.
• Engagement and consent: Document the patient’s and caregiver’s involvement in the re-evaluation process and their understanding of the new plan of care.
• Barriers or facilitators: Note any new factors affecting the patient’s functional performance, including environmental, physical, or cognitive challenges.

Ensure all documentation supports appropriate reimbursement and aligns with current procedural terminology (CPT) and Medicare physician fee schedule requirements.

Billing guidelines

CPT code 97168 is billed once per medically necessary re-evaluation event. This occupational therapy service is used to assess changes in the patient’s condition, functional status, or treatment goals, and must be supported by accurate documentation and clinical findings.

• Although not explicitly timed, a re-evaluation typically requires about 30 minutes of face-to-face clinical effort for assessment and planning.
• This procedure code should not be billed routinely or based solely on time passage. It must be triggered by a significant change, such as new clinical findings, lack of patient’s progress, or a revised plan of care.
• When services fall under an occupational therapy established plan, use modifier GO to indicate compliance with Medicare and coding practices.
• Documentation must support that the ot re-evaluation was a medically necessary service, reflecting the occupational therapist’s professional judgment.
• Avoid overlap with initial evaluation codes or other therapy evaluation services unless justified by clinical judgment and the patient’s history.

Following these billing guidelines ensures appropriate reimbursement, meets Medicaid services or Medicare physician fee schedule standards, and reflects effective treatment planning under the American Medical Association’s CPT framework.

Other relevant CPT codes

• 97165–97167 – OT evaluations (low to high complexity)
• 97530 – Therapeutic activity
• 97535 – ADL training