CPT 97164
Global XXX ActivePt re-eval est plan care
CPT 97164 Billing & Documentation Guide
CPT code 97164 (Pt re-eval est plan care) is classified under Physical Medicine with a global period indicator of XXX. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 0.96, a non-facility practice expense RVU of 1.05, and a malpractice RVU of 0.01, a total non-facility RVU of 2.02 and facility RVU of 2.02. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $69.61, though rates vary from $62.36 to $86.34 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 97164, ensure documentation supports medical necessity and the specific components required for the code's level of service. For E/M codes, document MDM (medical decision-making) elements: problems addressed, data reviewed, and risk. For procedural codes, document the indication, technique, and any complications. Always verify NCCI edits before bundling 97164 with related codes; this code has 10 PTP bundling relationships on file (see table below).
Payment Status & Global Period
Active code (paid under MPFS)
No global period (E/M and other non-procedural services)
MUE Limit (Medically Unlikely Edits)
Submitting more than 1 units of 97164 for the same patient on the same date triggers automatic line denial unless an appropriate modifier and supporting documentation justify the higher quantity.
RVU Breakdown, CPT 97164
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 0.96 | 0.96 |
| Practice Expense RVU | 1.05 | 1.05 |
| Malpractice RVU | 0.01 | 0.01 |
| Total RVU | 2.02 | 2.02 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 97164
State-level averages across all MAC localities. Non-facility rates typically apply to office-based services; facility rates apply to hospital outpatient / inpatient.
| State | Non-Facility | Facility | Range (Non-Fac) | Localities |
|---|---|---|---|---|
| California | $74.89 | $74.89 | $71.23 - $86.34 | 29 |
| Florida | $67.9 | $67.9 | $66.09 - $69.42 | 3 |
| Georgia | $65.97 | $65.97 | $63.75 - $68.19 | 2 |
| Illinois | $66.7 | $66.7 | $64.61 - $68.9 | 4 |
| Michigan | $65.47 | $65.47 | $64.46 - $66.47 | 2 |
| North Carolina | $65 | $65 | $65 - $65 | 1 |
| New York | $73.16 | $73.16 | $65.62 - $76.44 | 5 |
| Ohio | $64.42 | $64.42 | $64.42 - $64.42 | 1 |
| Pennsylvania | $67.07 | $67.07 | $64.58 - $69.55 | 2 |
| Texas | $67.08 | $67.08 | $64.29 - $69.53 | 8 |
Source: CMS PFSRVU 2026 · Updated 2026-04-01. Full locality-level detail available for all 53 states, contact us for custom reports.
NCCI Bundling Edits, CPT 97164
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 97164 on the same date of service, review the modifier indicator and payer policy before submission.
| Partner Code | Relationship | Modifier Allowed | Rationale |
|---|---|---|---|
| 0213T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0213T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0216T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0216T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0228T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0228T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0229T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0229T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0230T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0230T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
Frequently Asked Questions, CPT 97164
What does CPT code 97164 mean? +
CPT code 97164 represents: Pt re-eval est plan care. It's in the Physical Medicine category with a global period of XXX.
What is the Medicare reimbursement for CPT 97164? +
The 2026 Medicare national average non-facility payment for CPT 97164 is $69.61. Rates range from $62.36 to $86.34 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 97164? +
Medicine section spans a wide range: therapy services use GP/GO/GN (PT/OT/SLP plans of care) and KX (above cap with documentation). Drug administration uses JW (waste) and JZ (no waste). Professional/technical split applies to some diagnostic codes.
What bundling edits apply to CPT 97164? +
This code has 10 NCCI PTP bundling relationships. See the NCCI Bundling section below for full list.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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