CPT 97162Physical Therapy

Pt eval mod complex 30 min

CPT 97162 is a billing code for a physical therapy evaluation of moderate complexity, typically lasting 30 minutes, for patients with multiple body areas affected or comorbidities that complicate treatment planning.

Showing rates for

National Average

Base Medicare rate

$98.01

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

1.54

PE RVU (NF)

1.45

MP RVU

0.04

Total RVU

3.03

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Document all three complexity factors: clinical presentation with evolving symptoms, clinical decision-making affecting 3+ variables, and multiple treatment options considered
Impact: Proper documentation prevents $23-31 downcoding to 97161 and supports the full $98.01 reimbursement
Include objective measures and standardized tests (e.g., Berg Balance Scale, Timed Up and Go, gait speed) to demonstrate moderate complexity
Impact: Objective outcome measures strengthen medical necessity and reduce audit risk by 40-60% according to OIG reports
Bill 97162 only once per discipline per episode of care; subsequent re-evaluations should use 97164
Impact: Incorrect repeat billing of 97162 triggers automatic denials; 97164 pays $64.27, and proper coding avoids $33.74 recoupment
Ensure the evaluation takes approximately 30 minutes face-to-face; document start and end times to support time-based intensity
Impact: Significant time variance (under 20 or over 40 minutes) may trigger audits or downcoding requests
Never bill 97162 on the same day as 97161 or 97163; only one evaluation code per discipline per day is reimbursable
Impact: Duplicate evaluation billing results in 100% denial of the second code and potential fraud investigation
Use the GP modifier consistently on all Medicare PT claims; verify payer-specific modifier requirements for commercial insurers
Impact: Missing GP modifier causes immediate Medicare denial of the entire $98.01; some MAC contractors auto-deny without manual review opportunity

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Frequently asked questions

What is the difference between CPT 97161, 97162, and 97163?

97161 is for low complexity PT evaluations with stable, uncomplicated conditions requiring straightforward clinical decisions. 97162 is for moderate complexity with evolving presentations, stable chronic conditions, or multiple body regions requiring consideration of 3+ treatment variables. 97163 is for high complexity with unstable conditions, multiple comorbidities, or complex clinical decision-making affecting numerous treatment options. The 2025 Medicare rates are $74.70 (97161), $98.01 (97162), and $129.72 (97163).

How much does Medicare pay for CPT code 97162 in 2025?

Medicare pays $98.01 for CPT 97162 in 2025 based on the national average non-facility rate. This rate is the same for both facility and non-facility settings. The code has 3.03 total RVUs (1.54 work RVU, 1.45 practice expense RVU, 0.04 malpractice RVU) multiplied by the 2025 conversion factor of 32.3465.

Can you bill 97162 more than once for the same patient?

Generally no. CPT 97162 should only be billed once per discipline per episode of care. If the patient requires re-assessment during the episode, use 97164 (PT re-evaluation). You may bill 97162 again only if there is a significant change in condition, new diagnosis, or a completely new episode of care after discharge, and this must be clearly documented with medical justification.

What modifiers are required for billing CPT 97162?

Medicare requires the GP modifier on all physical therapy services including 97162 to designate the service as PT rather than occupational therapy or speech therapy. The KX modifier is required when exceeding therapy cap thresholds. Modifier 76 may be needed for repeat evaluations by the same therapist when medically justified, though this is rare for initial evaluations.

How long should a 97162 physical therapy evaluation take?

CPT 97162 is designed for approximately 30 minutes of face-to-face time with the patient. While not strictly time-based, the moderate complexity evaluation typically requires this duration to complete history, examination, clinical decision-making, and plan of care documentation. Significant deviations (under 20 or over 40 minutes) may trigger questions about appropriate code selection.

What documentation is needed to support medical necessity for 97162?

Documentation must include patient history with relevant comorbidities, objective examination findings with measurements, standardized outcome measures, evidence of moderate clinical complexity (stable chronic conditions or evolving symptoms affecting multiple body regions), clinical decision-making considering 3+ treatment options, PT diagnosis using ICF framework, and a specific plan of care with measurable functional goals. The evaluation should clearly demonstrate why moderate complexity (97162) is appropriate rather than low (97161) or high (97163).

Can CPT 97162 and 97110 be billed on the same day?

No. CPT 97162 is an evaluation code and should not be billed with treatment codes like 97110 (therapeutic exercise) on the same day of service. The evaluation is a comprehensive assessment to develop the plan of care; treatment typically begins at a subsequent visit. Billing both on the same day will likely result in denial of the treatment code or bundle both services, resulting in payment for only the evaluation.