Understanding Elements in Physical Therapy CPT Codes

CPT codes, established and maintained by the American Medical Association (AMA), are standardized codes used to define medical, surgical, and diagnostic services. In 2017, significant changes were introduced in physical therapy billing and reporting practices, which remain relevant in 2025. 

These changes included the removal of PQRS (Physician Quality Reporting System) reporting requirements and the introduction of a tiered system for physical therapy evaluation codes, replacing the previous single code used for PT evaluations. 

While this system has been in place for several years, many therapists in outpatient settings still seek a deeper understanding of its structure and application.

This article explores the elements of physical therapy CPT, their role in billing, and a detailed overview of the three levels of complexity. Whether you are a clinician or billing specialist, having a clear grasp of how element code PT classifications function will improve accuracy in reporting. 

Standard Elements in Physical Therapy CPT Codes

The term 'elements' refers to specific components that are assessed during patient evaluations. According to the APTA, these elements encompass various aspects such as body structures, functions, activity limitations, and participation restrictions. 

1. Evaluation: This involves an initial assessment to understand the patient's condition, followed by follow-up evaluations to track progress and adjust the treatment plan.
2. Therapeutic Procedures: These are treatments aimed at improving strength, flexibility, range of motion, and coordination. They can include exercises, neuromuscular reeducation, and gait training.
3. Modalities: These treatments use physical agents like heat, cold, ultrasound, or electrical stimulation to help with pain relief, healing, and muscle function.
4. Reevaluation: Periodic assessments are done to monitor progress and make necessary adjustments to the therapy plan.
5. Time-Based Treatments: Some therapies are billed based on the time spent on treatment sessions, typically in 15-minute increments.
6. Specialized Services: These include specific types of therapy like self-care management training or wheelchair management to improve daily functional abilities.

These elements are combined to create a personalized treatment plan aimed at helping the patient recover or manage their condition.

Understanding the role of element code in PT is crucial, as they form the foundation for accurately classifying the complexity of a patient's evaluation. 

What are the Levels of Complexity in PT Evaluations? 

There are three distinct evaluative codes that are categorized based on the complexity of the patient’s condition. According to the APTA, these codes reflect varying levels of evaluation complexity, which are expected to contribute to enhanced payment reform from CMS.

• 97161: Low complexity evaluation
• 97162: Moderate complexity evaluation
• 97163: High complexity evaluation

97164: Reevaluation code

Let’s understand this better. 

1. 97161: Low Complexity Evaluation

This code applies when a physical therapist evaluates a patient with low-complexity needs. The process involves reviewing the patient’s history, conducting basic tests, and developing a treatment plan. Key aspects of the evaluation include assessing movement patterns, muscle strength, range of motion, pain levels, and any functional challenges.

2. 97162: Moderate Complexity Evaluation

The evaluation under this code requires a more detailed approach, factoring in a broader medical history, the presence of comorbidities, and more significant functional impairments.

3. 97163: High Complexity Evaluation

For high complexity evaluations, applying the correct element code in physical therapy involves analyzing intricate medical conditions and severe functional impairments and formulating advanced treatment plans. High-complexity assessments require significant expertise to address the patient’s unique challenges effectively.

4. 97164: Reevaluation CPT Code 

A physical therapy reevaluation is performed when there has been a significant change in a patient’s condition or treatment plan since their initial evaluation. This situation could occur if the patient experiences a setback, such as reinjury or a noticeable decline in physical function.

Platforms like Spry’s AI-powered documentation feature can streamline your practice’s evaluations, therapeutic procedures, and progress tracking, improving efficiency and accuracy across all levels of care. Schedule a Free AI demo today! 

Criteria for Reevaluation CPT Code 97164

CPT Code 97164 is used for reevaluation when there is a need to reassess the patient’s progress and adjust the treatment plan based on significant changes in their condition. You should consider a reevaluation CPT Code when there is a,

• Significant Change in Condition: When there is a major shift in the patient’s physical status, such as new injuries, reduced functional abilities, or increased pain.
• Detailed Reassessment: The physical therapist conducts a detailed reassessment, which may include reviewing medical history and testing range of motion, strength, flexibility, balance, and other functional abilities.
• Treatment Plan Adjustment: Based on the reassessment, modifications to the treatment plan are made, such as changing therapeutic exercises, altering session intensity or frequency, or revising goals.

A Real-Life Example of Identifying Elements in Assessments

To understand the elements better, let’s consider a real-life example to identify the standard elements in PT assessments. 

A 42-year-old woman named Sarah recently had a skiing accident. During her last run, she lost control and collided with a tree, resulting in a partial tear of her ACL (Anterior Cruciate Ligament) in the knee. After undergoing surgery and completing 4 weeks of recovery, Sarah visits the clinic for her initial physical therapy evaluation and states the following:

1. Pain as an element code in evaluations: Sarah reports persistent knee pain, particularly when walking or standing for extended periods.
2. Range of motion limitations as an element: She struggles with bending and straightening her knee fully, limiting her range of motion.
3. Impairments in muscle functions as an element: Sarah mentions that her knee feels weak, and she cannot bear significant weight on her injured leg.
4. Other elements, such as positional inability: Sarah has difficulty transitioning between sitting and standing positions due to discomfort and instability in her knee.

Results: These 4 identified elements classify Sarah’s evaluation as a 97163 (high complexity evaluation) due to the multiple challenges she faces following her ACL injury. Her persistent knee pain, limited range of motion, muscle weakness, and difficulty transitioning between positions indicate an unstable clinical presentation.

Let’s consider another real-life example. 

A 30-year-old man visits a PT clinic with mild swelling and discomfort after playing basketball. He has no significant medical history or prior injuries affecting his ankle.

During the evaluation, the Physical Therapist assess his range of motion, strength, and balance. The findings indicate that while he experiences some pain, his condition is stable and uncomplicated. Based on this assessment, PT develops a treatment plan focused on reducing pain, improving mobility, and preventing future injuries.

Results: This scenario exemplifies a low complexity evaluation (CPT Code 97161) because it involves a clear clinical presentation with minimal impairments and no comorbidities.

To deepen your understanding of how physical therapists assess and address various factors affecting patient outcomes, consider exploring the following resources.

Further Study and Resource Recommendations

The International Classification of Functioning, Disability and Health (ICF) is a framework developed by the World Health Organization (WHO) that helps physical therapists understand and describe health and disability related to patients' functioning. 

It emphasizes the interaction between health conditions, environmental factors, and personal factors, allowing therapists to assess the medical diagnosis and how these elements affect a patient's daily life and rehabilitation process. 

For further reading on the ICF, you can refer to the following official sources:

• ICF Overview - World Health Organization
• ICF Manual - Physio-pedia

Physical therapists can also benefit from various educational resources available through professional organizations and seminars where they provide insights into best practices, research, and education opportunities that can enhance your clinical skills and knowledge.

For more information on educational resources, check out: APTA's Educational Resources

Conclusion

Understanding the elements of physical therapy evaluations is crucial for refining clinical assessments and ensuring optimal patient outcomes. By accurately identifying and documenting element code in PT, you can classify evaluations effectively, which enhances decision-making. This classification will not only be helpful in treatment planning but also impact billing and compliance with industry standards.

To simplify these processes, Spry PT provides an effective solution. Its digital charting and analytics features enable seamless tracking of patient progress and adherence, ensuring precise documentation of all relevant elements. 

Spry PT supports accurate coding, enhances practice efficiency, and helps deliver outstanding patient care while protecting your practice’s financial stability. Schedule a free demo Today!