Billing for occupational therapy can feel like walking through a maze.
You know you did the work. You spent time with the patient. You reassessed their progress. But when you look at the list of CPT codes, you hesitate. Which one is right for a reevaluation?
This happens to many OT practitioners.
The good news is that choosing the correct OT reevaluation CPT code does not have to be complicated. Once you understand the logic behind the codes, the decision becomes much clearer.
In this guide, we will walk through everything you need to know. You will learn the difference between an initial evaluation, a reevaluation, and a progress check. You will see exactly when to use each code. And you will get practical tips to avoid claim denials.
What Is an OT Reevaluation?
Before we talk about codes, let us define what a reevaluation actually means in occupational therapy practice.
A reevaluation is not the same as a progress note. It is also not the same as a daily treatment note where you briefly check how a patient is doing.
A true reevaluation is a formal reassessment of the patient’s condition. It happens after a significant period of time. Or it happens when something major changes in the patient’s status.
During a reevaluation, you will typically:
- Review the patient’s current functional status
- Re-administer standardized assessments
- Compare current performance to previous goals
- Identify new barriers or challenges
- Modify the plan of care
- Update short-term and long-term goals
Medicare and most private payers expect a reevaluation to be a separate, billable service. But you cannot bill it every week. You need a valid reason.
“A reevaluation is not a routine check-in. It is a clinical decision point that changes the course of treatment.” — Anonymous billing specialist
The Main OT Reevaluation CPT Code: 97168
The most common code for an OT reevaluation is 97168.
This code falls under the physical medicine and rehabilitation section of the CPT manual. It is specifically for occupational therapy.
Here is the official description of 97168:
*Occupational therapy reevaluation. Typically, 30 minutes are spent face-to-face with the patient and/or family.*
But let us break that down.
The code includes:
- Review of the patient’s current status
- Reassessment using standardized or non-standardized tests
- Clinical decision-making
- Modification of the treatment plan
- Goal revision
- Communication with the patient or family
You do not need to spend exactly 30 minutes. The descriptor says “typically.” That means 30 minutes is the average. Some reevaluations take 20 minutes. Some take 45. The key is that the service must be medically necessary and appropriately documented.
When to Use 97168
Use 97168 when:
- The patient has completed several weeks of therapy
- You need to formally reassess progress
- Goals have been met or are no longer appropriate
- The patient’s condition has changed (for better or worse)
- You are considering discharge but want to reassess first
- A payer requires a formal reevaluation every 30 or 60 days
When NOT to Use 97168
Do not use 97168 for:
- A routine progress note (use 97165 for re-eval? No — wait, we clarify this below)
- A quick check-in at the start of a session
- A discharge summary without a formal reassessment
- The same visit as an initial evaluation (use 97165 instead)
Let us clarify something important. There is often confusion between 97168 and 97165.
Comparison Table: 97168 vs. 97165 vs. 97166
Many therapists ask: Is 97165 a reevaluation code?
The answer is no. 97165 is the code for an initial evaluation with low complexity.
Here is a quick comparison to help you see the difference.
| CPT Code | Service Type | Typical Time | Complexity Level | When to Use |
|---|---|---|---|---|
| 97165 | Initial evaluation | 30 minutes | Low | First visit, straightforward cases |
| 97166 | Initial evaluation | 45 minutes | Moderate | First visit, moderate complexity |
| 97167 | Initial evaluation | 60 minutes | High | First visit, complex patients |
| 97168 | Reevaluation | 30 minutes (typical) | Any | After established treatment period |
Notice that 97168 does not have low, moderate, or high complexity distinctions. That is because a reevaluation is considered one service. You either perform a reevaluation or you do not.
Some payers may ask you to use 97168 with a modifier. But in most cases, it stands alone.
Can You Bill 97168 and a Treatment Code on the Same Day?
This is a very common question.
The short answer is: Yes, but carefully.
You can bill 97168 (reevaluation) and a therapeutic procedure code (such as 97110, 97530, or 97112) on the same day. However, you must follow two important rules.
Rule 1: The Reevaluation Must Be Separate
The reevaluation cannot happen in the middle of a treatment session without a clear reason. For example, if you planned to do 30 minutes of therapeutic exercise, but 10 minutes in you decide to stop and do a reevaluation, that is not appropriate.
Instead, the reevaluation should be a distinct part of the visit. Many therapists schedule a separate appointment for reevaluations. Others perform the reevaluation at the start of a session and then move to treatment. Both approaches can work if documented clearly.
Rule 2: Use Modifier 59 or XU
To show the payer that the reevaluation was separate from the treatment, you will likely need to add a modifier.
- Modifier 59 (Distinct Procedural Service) is the traditional choice.
- Modifier XU (Unusual Non-Overlapping Service) is more specific and often preferred by Medicare.
Without a modifier, the payer may bundle the reevaluation into the treatment code and deny payment.
Example of Same-Day Billing
| Time | Service | Code | Modifier |
|---|---|---|---|
| 8:00 AM – 8:30 AM | Reevaluation (review goals, update POC, re-administer assessment) | 97168 | 59 |
| 8:30 AM – 9:00 AM | Therapeutic exercise | 97110 | None |
Total billed: 97168-59 and 97110.
Reevaluation vs. Progress Note: A Critical Distinction
This is where many claims get denied.
A progress note is not a reevaluation. Even if you write a very detailed progress note, it does not automatically qualify for 97168.
So what is the difference?
| Feature | Progress Note | Reevaluation (97168) |
|---|---|---|
| Frequency | Every visit or weekly | Every 30–60 days or with significant change |
| Standardized tests | Optional | Usually required |
| Goal revision | Minor updates | Formal goal rewriting |
| Plan of care change | Rarely | Often |
| Billable separately | No (included in treatment) | Yes |
If you are writing a note that simply says “Patient continues to make progress toward goals,” that is a progress note. Keep it as part of your daily treatment billing.
If you are stopping treatment for 20–30 minutes to formally reassess, re-administer a standardized tool, and rewrite the plan of care, that is a reevaluation.
Medicare and OT Reevaluation Rules
Medicare has specific guidelines for 97168. If you bill Medicare, you need to know these rules.
Medicare Coverage Summary
- Medicare covers outpatient OT reevaluations when medically necessary.
- The reevaluation must be ordered by a physician or NPP (non-physician practitioner) as part of the plan of care.
- A reevaluation is typically allowed every 30 days. However, Medicare does not have a strict “one per month” rule. You can do it more often if the patient’s condition changes significantly.
- If the patient has not been seen for 30 days or more, you may need to perform a new initial evaluation (97165-97167), not a reevaluation. Check your local MAC guidelines.
Medicare Documentation Requirements
To support 97168, your note must include:
- Reason for reevaluation – Why is it necessary today?
- Current functional status – Objective and subjective findings
- Comparison to prior status – What has changed since the last evaluation?
- Standardized or reproducible assessment – You do not always need a formal standardized test, but you need a consistent, reproducible method
- Revised goals – Updated short-term and long-term goals
- Modified plan of care – What will you do differently going forward?
- Time spent – Total face-to-face time (even though it is untimed, documentation helps)
A Note on “Untimed”
Code 97168 is technically an untimed code. That means you do not bill based on 15-minute increments like you do with 97110. However, the CPT descriptor says “typically 30 minutes.” If you spend significantly less time (e.g., 10 minutes), you may not have performed a true reevaluation. If you spend significantly more (e.g., 60 minutes), you should document why it took longer.
Private Payer Policies for 97168
Medicare is one thing. Private payers can be completely different.
Some private insurance companies follow Medicare rules closely. Others have their own policies.
Common Private Payer Variations
- Frequency limits – Some payers allow a reevaluation only once every 60 or 90 days.
- Prior authorization – Some require prior auth for reevaluations, especially after the first one.
- Same-day billing restrictions – A few payers will not pay for 97168 and a treatment code on the same day under any circumstances.
- Time requirements – Some payers require a minimum of 30 minutes for 97168. If you bill 20 minutes, they may down-code or deny.
What You Should Do
- Check each payer’s policy – Do not assume. Look up the policy in writing.
- Call provider services – If the policy is unclear, call and ask. Document the date, time, and name of the representative.
- Keep a cheat sheet – Create a simple table for your clinic.
| Payer | Reevaluation Frequency | Same-Day Treatment Allowed? | Prior Auth Needed? |
|---|---|---|---|
| Medicare | As medically necessary (typically 30 days) | Yes, with modifier 59 or XU | No |
| Blue Cross (example) | Every 60 days | Yes, with modifier | Only after 12 visits |
| Aetna (example) | Every 30 days | Yes, but no modifier needed | No |
| UnitedHealthcare (example) | Every 90 days | Yes, with modifier 59 | For reeval #2 onward |
Note: These are examples only. Always verify with the actual payer.
Step-by-Step: How to Document 97168 Correctly
Good documentation is your best defense against denials and audits.
Here is a simple template you can adapt.
SOAP Note Template for 97168
Subjective
“Patient reports feeling stronger but still has difficulty with buttoning shirts. She states, ‘I want to work more on fine motor tasks.’”
Objective
Re-administration of the Canadian Occupational Performance Measure (COPM) shows:
- Performance score improved from 3/10 to 6/10
- Satisfaction score improved from 4/10 to 7/10
Nine-hole peg test: Right hand 32 seconds (previously 45 seconds). Left hand 38 seconds (previously 52 seconds).
Observation: Patient required moderate assistance for dressing upper body (previously maximum assistance).
Assessment
Patient has made meaningful progress in fine motor coordination and functional dressing. Current goals for buttoning and zippering have been partially met. New barrier identified: decreased endurance for sustained fine motor tasks. Reevaluation indicates need for adjusted plan of care.
Plan
Goals revised:
- Short-term goal (4 weeks): Independently button 3 large buttons in 60 seconds.
- Long-term goal (8 weeks): Independently manage all fasteners on a button-down shirt.
Plan of care modified: Add 15 minutes of fine motor endurance activities (clothespins, putty exercises) to each session. Reduce shoulder strengthening from 20 to 10 minutes. Continue 2x per week for 6 more weeks.
Face-to-face time with patient: 35 minutes.
That is a clean, defensible note for 97168.
Common Billing Mistakes and How to Avoid Them
Even experienced billers make mistakes. Here are the most common ones for OT reevaluation codes.
Mistake 1: Billing 97168 Too Often
Some therapists bill a reevaluation every 2 weeks “just to update goals.” That is a red flag.
How to avoid it: Only bill 97168 when a real clinical change has occurred or when a payer’s timeframe has been reached (e.g., every 30 days for Medicare). For minor updates, use a progress note.
Mistake 2: Billing 97168 Without a Standardized or Reproducible Assessment
You do not always need a formal standardized test like the COPM or the BOT-2. But you need something reproducible. “Patient looks better” is not enough.
How to avoid it: Use goniometer measurements, timed tests, functional reach tests, or any assessment that can be repeated and compared.
Mistake 3: Forgetting the Modifier for Same-Day Billing
You perform a 97168 in the first 30 minutes. Then you do 97110 for 30 minutes. You bill both. The claim gets denied because the payer bundled 97168 into 97110.
How to avoid it: Add modifier 59 or XU to 97168. Check your payer’s preference.
Mistake 4: Billing 97168 When the Patient Has Been Absent for Weeks
A patient stops coming for 45 days. Then they return. Can you bill 97168? Probably not. Most payers consider that a new episode of care requiring a new initial evaluation.
How to avoid it: Check your payer’s definition of “interruption in care.” For Medicare, a break of 30 days or more usually means a new evaluation.
What About Discharge? Is There a Discharge Reevaluation Code?
There is no specific CPT code for a discharge reevaluation.
Some therapists try to bill 97168 for a discharge visit. That is usually incorrect unless you are performing a full reevaluation and then discharging.
Here is the general rule:
- If the discharge is simply a final treatment session where you summarize progress, that is part of the last treatment code (e.g., 97110).
- If you perform a formal reevaluation (30+ minutes, standardized tests, goal update) and then decide to discharge, you can bill 97168 for that visit.
- Some payers expect a separate discharge assessment. For those, you may need to use a different code or no code at all. Check with each payer.
When in doubt, document thoroughly. If you performed the work of a reevaluation, bill it. If you just reviewed progress and said goodbye, do not bill a reevaluation.
97168 vs. 97150 (Group Therapy) – Can They Be Combined?
Group therapy (97150) is a common code in many OT settings. Can you perform a reevaluation in a group setting?
Technically, no.
CPT code 97168 specifies face-to-face time with the patient and/or family. It does not say “individual.” However, the nature of a reevaluation is one-on-one. You cannot properly re-administer a standardized test or have a detailed discussion about goal revision while also managing a group of other patients.
If you try to bill 97168 and 97150 on the same day, be prepared to justify why the reevaluation could not be done individually. Most auditors will flag this combination.
Best practice: Perform reevaluations in individual sessions only.
State Laws and Scope of Practice
Do not forget about your state’s practice act.
Some states have specific rules about who can perform a reevaluation. In most states, a licensed occupational therapist can perform a reevaluation without a physician’s order for the reevaluation itself (as long as the original plan of care was ordered). But some states are more restrictive.
Also, some states require that a reevaluation be performed by the same therapist who did the initial evaluation. Others allow any licensed OT.
What you should do: Look up your state’s OT practice act. Search for “reevaluation” or “reassessment.” If you cannot find a clear answer, contact your state licensing board.
Real-Life Scenarios: When to Bill 97168
Let us walk through a few realistic cases. This will help you apply the rules in practice.
Scenario 1: The Steady Progress Patient
A patient with shoulder impingement has been coming for 6 weeks, 2x per week. She has improved from 70 degrees of shoulder flexion to 140 degrees. She has met 3 out of 4 goals. You want to update her goals and adjust the plan.
Should you bill 97168? Yes. You have a clear reason (goals met, significant time passed). You will spend about 25 minutes reviewing, re-assessing, and rewriting goals. Bill 97168.
Scenario 2: The Sudden Decline
A patient with Parkinson’s disease was doing well. He fell at home last week. Now his balance is worse. He cannot perform transfers as before. You need to completely reassess him.
Should you bill 97168? Yes. A significant change in condition is a perfect reason. You can bill 97168 even if his last reevaluation was only 2 weeks ago. Document the change clearly.
Scenario 3: The Weekly Check-In
A patient with hand fracture comes 3x per week. At the start of each session, you ask how the hand feels, you watch him make a fist, and you note he is about the same as last time. You do not change goals or the plan.
Should you bill 97168? No. This is a progress check. It is part of your daily treatment. Bill your regular therapeutic procedure codes (97110, 97530, etc.) and document progress in the daily note.
Scenario 4: The Payer-Required Reevaluation
A commercial insurance plan requires a formal reevaluation every 60 days. The patient has been stable for 8 weeks. You do not want to do a reevaluation because nothing has changed. But the payer will deny further visits without one.
Should you bill 97168? Yes, but carefully. You still need to perform a meaningful reassessment. Do not just write “No change.” Re-administer a test. Even if results are the same, that is valuable information. Document why the reevaluation was required by the payer and why no changes were made to the plan.
Audits and Red Flags: What Payers Look For
Payers audit OT reevaluation codes for specific patterns. Here are red flags that increase your audit risk.
| Red Flag | Why It Is a Problem | How to Fix It |
|---|---|---|
| Billing 97168 every 2 weeks for the same patient | Suggests routine, not medically necessary | Space reevaluations appropriately (4+ weeks unless acute change) |
| 97168 with zero change to goals or POC | Raises question: Why was a reevaluation needed? | Always update goals or plan, even if only slightly |
| 97168 with less than 20 minutes of time | Too short for a true reevaluation | Only bill if you spend meaningful time (25+ minutes recommended) |
| No standardized or reproducible data | Subjective only = progress note, not reevaluation | Include at least one reproducible measure |
| 97168 billed on 100% of patients every 30 days | Mass billing pattern | Vary frequency based on clinical need |
If you see these patterns in your own billing, adjust your practices now. An audit is not fun.
Technology and 97168: Telehealth Reevaluations
Can you perform an OT reevaluation via telehealth?
It depends.
Medicare’s position (as of 2025): Medicare permanently allows certain OT services via telehealth. However, 97168 is not on Medicare’s permanent telehealth list. That means you generally cannot bill Medicare for 97168 via telehealth unless there is a public health emergency or specific waiver.
Private payers vary widely. Some allow telehealth reevaluations. Others do not. Some allow them only if a live video platform is used (not audio-only).
If you do perform a telehealth reevaluation:
- Document that the visit was via telehealth.
- Note which platform you used.
- Describe how you performed assessments without physical contact (e.g., functional observation, patient self-report, caregiver-assisted measurements).
- Add modifier 95 (synchronous telemedicine) if required by the payer.
Check each payer’s telehealth policy before billing 97168 remotely.
Important Notes for Readers
Here are some key takeaways to keep in mind.
Note 1: This guide is for informational purposes only. Billing rules change frequently. Always verify codes and guidelines with the latest CPT manual, your local MAC, and individual payer policies.
Note 2: When in doubt, document more, not less. A well-documented reevaluation that is denied can be appealed. A poorly documented reevaluation cannot.
Note 3: Do not let billing fears prevent you from performing necessary reevaluations. Clinical judgment comes first. If a patient needs a formal reassessment, do it. Just document correctly and choose the right code.
Note 4: Consider hiring a certified OT coder or taking a continuing education course on OT billing. The cost is often worth the prevention of denied claims.
Additional Resources
For more official information, visit the American Occupational Therapy Association (AOTA) billing and coding page:
https://www.aota.org/practice/practice-management/billing-and-reimbursement
This resource includes up-to-date guides, webinars, and payer-specific advice for AOTA members.
Frequently Asked Questions (FAQ)
1. What is the CPT code for an OT reevaluation?
The primary CPT code for an occupational therapy reevaluation is 97168.
2. Is 97165 a reevaluation code?
No. 97165 is an initial evaluation code for low-complexity patients. Use 97168 for reevaluations.
3. Can I bill 97168 and 97110 on the same day?
Yes, but you typically need to add modifier 59 or XU to 97168 to show it was a distinct service.
4. How often can I bill 97168 for the same patient?
There is no fixed rule, but Medicare and most private payers expect reevaluations every 30–90 days unless the patient’s condition changes significantly.
5. Do I need a physician’s order for a reevaluation?
In most cases, the original plan of care order covers reevaluations. However, some states or payers require a separate order. Check your local rules.
6. What happens if I bill 97168 without modifier 59 on the same day as treatment?
The payer may bundle the reevaluation into the treatment code and deny payment for 97168.
7. Can a COTA perform a reevaluation?
Generally, no. Medicare and most payers require a licensed occupational therapist (OTR) to perform reevaluations. A COTA may assist or contribute data, but the OT must be the provider of record.
8. Is there a time requirement for 97168?
The CPT descriptor says “typically 30 minutes.” There is no strict minimum, but a reevaluation under 20 minutes is unlikely to be accepted.
9. Can I bill 97168 for a discharge?
Only if you perform a full reevaluation (standardized tests, goal update, POC modification) and then discharge. Otherwise, do not bill it.
10. Where can I find official updates on OT reevaluation coding?
Visit the AOTA website or the CMS (Centers for Medicare & Medicaid Services) website. Both publish annual updates.
Conclusion
To summarize this guide in three lines:
The primary OT reevaluation CPT code is 97168. Use it when you formally reassess a patient after a significant period or clinical change, not for routine progress checks. Document thoroughly, add modifiers when billing same-day treatment, and always verify individual payer policies to avoid denials.
Disclaimer: This article is for educational purposes only and does not constitute legal or billing advice. CPT codes and payer policies change. Always consult the current CPT manual, your Medicare Administrative Contractor (MAC), and private payer policies before submitting claims. The author and publisher assume no responsibility for billing errors or claim denials resulting from the use of this information.
