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Healthfirst’s Failure to Reimburse Physical Therapy Evaluation Codes 97161, 97162, 97163, 97164

Updated: May 25, 2019

By: Steven Veroxie, Owner PhysioBilling, LLC - A Physical Therapy Billing Company

January 2019 New York Statewide. Clinics that we serve have been reporting non-payment on all physical therapy evaluation codes for all Healthfirst Plans. Evaluation codes 97161, 97162, 97163 and 97164 were all rejected with the reason “not a CMS recognized code.” We all know that Medicare and most insurance companies has been accepting these codes for the past few years. PhysioBilling attempted to bill Healthfirst with the outdated 97001 initial evaluation code. This older code was also rejected.

In January, PhysioBilling’s claim denial team reached out to Healthfirst directly. Healthfirst representatives explained that the submitted codes were unacceptable and physical therapists should bill under the Functional Evaluation Code 97750. PhysioBilling passed this information to our clinics. The 97750 code was also rejected. Clinical directors were becoming irate with Healthfirst. This issue continued into March 2019.

As we transitioned into spring, on April 1st. Like the snap of a finger Healthfirst began reimbursing for all PT evaluation codes. Healthfirst informed PhysioBilling that an error in their system has been corrected. All denied payments on eval codes will be corrected and paid. Beginning on May 1st, a large number of our clinics have reported seeing posted payments from Healthfirst January evaluations.

We share in all the frustration of each one our billing clients. It’s a relief that Healthfirst has finally corrected this costly error and have begun reprocessing these claims.

PhysioBilling continues to discover errors and unfair decisions on physical therapy claims all over New York State. Contact Healthfirst Provider Services to confirm that your unpaid evaluations will be reprocessed. If your clinic needs assistance concerning this or any other denied payment issues, please contact PhysioBilling today!


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