Summary & Overview

CPT 97168: Occupational Therapy Re-Evaluation of Established Plan of Care

CPT code 97168 is a critical billing code for occupational therapy, specifically addressing the re-evaluation of an established plan of care. This procedure is essential when a patient's functional or medical status changes, requiring a formal reassessment and update to their occupational profile and treatment goals. The code is widely recognized and reimbursed by major national payers, including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare, underscoring its importance in outpatient therapy settings across the United States.

This publication provides a comprehensive overview of CPT code 97168, detailing its clinical context, typical site of service, and the circumstances under which it is utilized. Readers will gain insight into payer coverage, relevant policy updates, and benchmarks for occupational therapy re-evaluations. The analysis also highlights associated modifiers, taxonomies, and common ICD-10 diagnoses linked to this service, offering a clear understanding of how 97168 fits within broader occupational therapy billing and clinical workflows. The information is designed to support healthcare professionals, administrators, and policy analysts in navigating the complexities of medical billing and reimbursement for occupational therapy re-evaluations.

AetnaBlue Cross Blue ShieldCigna HealthMedicareUnitedHealthcareCPT 97168occupational therapyre-evaluationoutpatient therapymedical billingclinical workflowpolicy updateICD-10modifiertaxonomies

CPT Code Overview

CPT code 97168 represents a re-evaluation of an occupational therapy established plan of care. This service involves an assessment of changes in the patient's functional or medical status, an update to the initial occupational profile to reflect any changes in condition or environment, and a revision of the plan of care. A formal re-evaluation is performed when there is a documented change in functional status or when a significant change to the plan of care is required. Typically, this service is provided in an outpatient therapy setting such as a clinic or office (Place of Service 11), and involves approximately 30 minutes of face-to-face time with the patient and/or their family.

Clinical & Coding Specifications

Clinical Context

A patient with an established occupational therapy plan of care returns to the outpatient clinic (Place of Service 11) due to a documented change in their functional status. For example, a patient previously treated for M62.81 (muscle weakness) and R26.2 (difficulty in walking) now reports increased difficulty with daily activities or new environmental challenges. The occupational therapist performs a formal re-evaluation, updating the occupational profile, assessing changes in medical or functional status, and revising the plan of care. Typically, this involves a 30-minute face-to-face session with the patient and/or their family to determine new goals and interventions.

Coding Specifications

Modifiers:
- Modifier 59: Distinct Procedural Service. Used when the re-evaluation is a separate and distinct service from other procedures performed on the same day.
- Modifier 76: Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional. Used when the same provider performs the re-evaluation more than once on the same day.
Provider Taxonomies:

Code Specialty
225X00000X Occupational Therapist
225XE0001X Occupational Therapist in Ergonomics
225XP0200X Occupational Therapist in Pediatrics

Code	Specialty
`225X00000X`	Occupational Therapist
`225XE0001X`	Occupational Therapist in Ergonomics
`225XP0200X`	Occupational Therapist in Pediatrics

These taxonomies represent providers qualified to perform occupational therapy re-evaluations, including those specializing in ergonomics and pediatrics.

Related Diagnoses

M62.81: Muscle weakness (generalized)
- Relevant for patients experiencing decreased strength, impacting their ability to perform daily activities and requiring occupational therapy interventions.
R26.2: Difficulty in walking, not elsewhere classified
- Indicates mobility challenges that may necessitate re-evaluation of therapy goals and strategies.
R29.6: Repeated falls
- Associated with safety concerns and functional decline, prompting reassessment of the occupational therapy plan.
M54.5: Low back pain
- Common musculoskeletal issue affecting function and participation in daily tasks, often requiring updated therapy approaches.
G54.0: Brachial plexus disorders
- Neurological condition impacting upper limb function, leading to changes in occupational performance and therapy needs.

Related CPT Codes

97165: Evaluation of occupational therapy, typically 30 minutes. Used for initial evaluations before a plan of care is established.
97166: Evaluation of occupational therapy, typically 45 minutes. Used for more complex initial evaluations.
97167: Evaluation of occupational therapy, typically 60 minutes. Used for highly complex initial evaluations.
97164: Re-evaluation of physical therapy established plan of care, typically 20 minutes. Used for physical therapy re-evaluations, not occupational therapy.

97165, 97166, and 97167 are commonly used for initial occupational therapy evaluations, while 97168 is used for formal re-evaluations when there is a change in functional status or plan of care. 97164 is an alternative for physical therapy re-evaluations, not occupational therapy.

National Reimbursement Benchmarks

Medicare's national mean rate for CPT code 97168 is $71.13, closely aligned with the BUCA (average commercial) mean rate of $68.94. Among commercial payers, Cigna and UnitedHealth Group report the highest mean rates at $79.79 and $78.12, respectively, while Aetna is the lowest at $58.61.

Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare exhibits the tightest range ($6.00), indicating relatively consistent reimbursement. In contrast, Cigna shows the widest dispersion ($44.00), reflecting greater variability in rates. Blue Cross Blue Shield and BUCA also display broader ranges ($26.17 and $26.89, respectively).

The table and chart below present a detailed breakdown of national benchmarks for CPT code 97168 by payer.

National Mean Rates for CPT Code `97168` by Payer

Related Codes

97763

CPT 97763: Orthotic and Prosthetic Management, Subsequent Encounter

99310

CPT 99310: Subsequent Nursing Facility Care, High Complexity

97546

CPT 97546: Additional Hour of Physical Medicine & Rehabilitation Therapeutic Procedures

29450

CPT 29450: Application of Long or Short Leg Clubfoot Cast

97012

CPT 97012: Mechanical Traction Therapy in Physical Medicine

99306

CPT 99306: Initial Nursing Facility Care, High Complexity Evaluation and Management

99309

CPT 99309: Subsequent Nursing Facility Care, Moderate Complexity

29580

CPT 29580: Application of Unna Boot for Wound Care and Orthotic Strapping

29705

CPT 29705: Removal or Repair of Casts and Strapping

29044

CPT 29044: Application of Body Cast, Shoulder to Hips and Down One Thigh

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