CPT 97164: Physical Therapy Re-evaluation, Plan of Care Revision
Medicare pays $70 and commercial payers pay $127 on average nationally for this procedure.
CPT code 97164 describes a physical therapy re-evaluation performed by a licensed provider (typically a physical therapist) that includes history review, standardized tests and measures of body structure and function, and revision of the plan of care using a standardized instrument and measurable functional outcome assessment tool; the service is typically a face-to-face outpatient or clinic-based therapy encounter lasting about 20 minutes with the patient and/or family.
For related coverage guidance, see recent payer policy updates: Lumbar Microdiscectomy, Artificial Cervical Intervertebral Disc, Lumbar Decompression.
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National Reimbursement Benchmarks
National commercial averages sit above Medicare for CPT 97164: Blue Cross Blue Shield’s mean of $168 and BUCA’s mean of $127 both exceed Medicare’s mean of $70.1, indicating commercial payers generally reimburse at higher levels than Medicare for this service. Cigna ($71.6), Aetna ($69.8), and UnitedHealth Group ($75.3) cluster near Medicare’s mean, while Blue Cross Blue Shield and BUCA pull the overall commercial mean upward.
Dispersion measured as the interquartile range (P75−P25) varies notably across payers. Blue Cross Blue Shield has the widest IQR at $140.5 (P75 $228.5 − P25 $88.0), reflecting substantial variability in commercial contracting. UnitedHealth Group’s IQR is $25.5 and Cigna’s is $36.0, showing tighter distributions; Aetna’s IQR is $44.0. BUCA’s IQR is $59.8 and Medicare’s IQR is $6.0, with Medicare demonstrating the tightest band around its mean.