What Is CPT 97162? Requirements, Billing Rules & Reimbursement
CPT code 97162 is an untimed, service-based code used only for a moderate complexity physical therapy evaluation. The American Medical Association (AMA) introduced it in 2017 to replace the single 97001 code, so physical therapists match each patient to a tier: low (97161), moderate (97162) or high (97163).
CPT 97162 is the code for a moderate complexity physical therapy evaluation. A licensed physical therapist bills it as one untimed unit when the patient has one or two personal factors or health conditions that shape the plan of care, three or more exam elements, and symptoms that are still changing. In 2026, Medicare pays about $98 for it nationally, the exact same amount as the low and high complexity evaluation codes.
That surprises a lot of clinic owners. It also means the money risk with 97162 isn’t the rate. It’s documentation gaps and small claim errors that stop payment cold.
What is CPT code 97162 in plain words?
Every physical therapy case starts with an evaluation. The therapist hears the patient’s story, runs tests and writes the plan of care that every later visit depends on.
CPT code 97162 is how that first visit gets billed when the case sits in the middle. Picture a 62-year-old with right knee pain after a fall. She also has type 2 diabetes and a desk job that keeps her sitting nine hours a day. That’s more than a simple ankle sprain and far less than a stroke patient with heart disease. That middle ground is what “moderate complexity” means.
What are the CPT 97162 requirements?
The AMA defines 97162 by four parts, and the evaluation note has to support all four:
History: one or two personal factors or health conditions that change the plan of care. Diabetes slowing healing counts. So does a desk job that keeps someone sitting all day.
Exam: standardized tests covering three or more elements, such as strength, range of motion, walking, stairs, or getting back to work.
Clinical presentation: evolving. Swelling that comes and goes, or pain that moves around week to week.
Decision making: moderate, backed by a standardized assessment tool or a measurable functional outcome score.
Typical face-to-face time is 30 minutes.
One requirement sits outside the code book. Only a licensed physical therapist can perform the evaluation, and the claim must carry that PT’s own enrolled NPI. A PTA can’t do it, and an unlinked rendering provider gets rejected, which is why clean NPI and taxonomy setup matters before the first evaluation is scheduled.
CPT 97161 vs 97162 vs 97163: how do you pick the right level?
Pick the level that all four parts support. If three parts point to moderate but the history shows no complicating factors, the claim belongs at 97161.
97161 (low) | 97162 (moderate) | 97163 (high) | |
Personal factors or comorbidities | None | 1 to 2 | 3 or more |
Exam elements | 1 to 2 | 3 or more | 4 or more |
Clinical presentation | Stable | Evolving | Unstable |
Typical time | 20 min | 30 min | 45 min |
2026 Medicare national rate | About $98 | About $98 | About $98 |
Re-evaluation has its own code, 97164. Use it for new clinical findings or a real change in the patient, not for routine progress checks.
CPT 97162 billing rules your claim has to follow
Bill one unit, every time. A 25-minute evaluation and a 50-minute evaluation both go out as one unit of 97162.
Add the GP modifier for Medicare. It’s an “always therapy” code, and Medicare returns it without GP. Many commercial plans ask for it too.
Get the plan of care signed. Medicare wants the physician or NPP to certify it within 30 days of the first treatment visit.
Leave 97164 off the same date. An evaluation and a re-evaluation on one day is a bundling denial.
Track the KX threshold. The evaluation counts toward 2026’s $2,480 limit for PT and speech therapy combined.
Check authorization for what comes next. Plenty of commercial and Medicare Advantage plans skip approval for the evaluation but require it for later visits. Our prior authorization services for therapy practices catch that before visit two goes unpaid.
Here’s how the knee patient’s claim looks:
Line | Code | Units | Diagnosis |
1 | 97162-GP | 1 | M25.561 (right knee pain), E11.9 (type 2 diabetes) |
2 | 97110-GP | 2 | M25.561 |
The 25 minutes of exercise bill as two units under the 8-minute rule. The evaluation minutes don’t count toward that total.
How much does CPT 97162 pay in 2026?
Medicare’s 2026 national rate for CPT 97162 is about $97.86: 2.93 total RVUs times the 2026 conversion factor of $33.4009. Your locality moves that number up or down. After the Part B deductible, Medicare pays 80% and the patient or a secondary plan covers 20%.
CMS gives 97161, 97162 and 97163 identical RVUs. So coding a moderate case as 97163 adds zero Medicare dollars and invites an audit.
Commercial payers set their own rates by contract, and some do pay more for higher tiers, so read your fee schedules line by line. Also confirm the claim shows where the visit happened, because place of service code denials can stall a perfectly coded evaluation.
Two CPT 97162 billing myths that still cost clinics money
Myth | Fact |
97530 can never be billed the same day as 97162. | CMS deleted that edit in 2020, retroactive to January 1, 2020. With both documented, Medicare pays both. |
97140 with 97162 always needs modifier 59. | That edit was lifted in 2020 too. Check the current NCCI table and each commercial contract before adding 59 out of habit. |
Both myths still circulate, and clinics drop billable treatment on evaluation day because of them.
Why do CPT 97162 claims get denied?
Most 97162 denials aren’t clinical. They’re clerical, and they repeat until someone fixes the step that caused them.
Denial trigger | What usually happened | The fix |
Missing GP modifier | Charge entry skipped it | Build GP into every Medicare eval charge |
Complexity not supported | Audit found no comorbidities in the note | Name the factors and the outcome tool used |
Wrong rendering provider | PTA listed, or PT not enrolled | Confirm enrollment before booking evals |
97164 on the same day | Added out of habit | Bill 97162 alone |
Follow-up visits unpaid | Plan needed approval after the eval | Send the request on eval day |
If one reason keeps showing up on your remits, compare it with these common medical claim denial reasons. The pattern usually leads back to one front-desk step.
Getting CPT 97162 claims paid the first time
The evaluation is the first claim in every episode of care. When it bounces, the authorization clock and every visit after it can stall too. For a small PT clinic, that’s weeks of earned money sitting in A/R.
Pacemave’s billers check therapy claims before they leave: modifiers, rendering NPI, authorization status and plan-of-care dates. That habit is a big part of how we hold a 98.9% clean claim rate. When something slips anyway, our denial management services trace it to the step that caused it, so it doesn’t come back next month.
CPT 97162 FAQs
Is CPT 97162 a timed code?
No. CPT 97162 is untimed, so you bill one unit per evaluation no matter how long it runs. The 30 minutes is a typical time, not a minimum. The 8-minute rule applies only to timed codes billed with it, such as 97110 or 97140.
Can 97162 and 97140 be billed on the same day?
Yes, under Medicare. CMS removed the edits bundling PT evaluation codes with 97140 and 97530 in 2020. The manual therapy needs its own documented minutes, separate from the evaluation. Some commercial payers still run their own bundling rules, so check each contract.
How often can CPT 97162 be billed?
Once per episode of care. A new 97162 usually fits when a patient starts care for a new condition or comes back after being discharged. For a mid-treatment reassessment of the same condition, bill re-evaluation code 97164 instead, and only when there’s a real change or new clinical information
