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 PhysioBilling attempted to bill Healthfirst with the outdated 97001 initial evaluation code.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!
(516)780-0132
physiobilling.com
Reading this post brought back a frustrating episode from last year when I needed a comprehensive PT evaluation after a shoulder injury. My therapist submitted codes 97161 and 97162 for the initial and subsequent evaluations, only to get a denial from Healthfirst with a vague “non-covered service” note. I spent hours on the phone, navigating automated menus and finally reaching a supervisor who explained that their system didn’t recognize those specific codes. After filing an appeal and providing extra documentation, the claim was finally approved—but not before I had to cover the out‑of‑pocket cost for weeks. It felt like the insurer was penalizing clinicians for following best practices, and it left me worried about future care. I’ve since switched to…
Reading this post brought back a frustrating episode from last year when my mom needed a comprehensive PT evaluation after her rotator cuff surgery. The therapist submitted the exact codes 97161 through 97164, hoping to get a full assessment covered, but Healthfirst denied them, labeling them “non‑billable.” We spent weeks on phone calls, sending faxes, and finally appealing the decision. It felt like we were fighting a bureaucratic maze while she was still in pain and needed proper guidance on her rehab plan. Eventually, after escalating to a supervisor, they approved only the first code, leaving the rest unpaid, which forced us to pay out of pocket for the detailed evaluation that shaped her recovery. It’s disheartening to see insurers…