CPT 97162 Fee Schedule
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
| Key Fact | Detail |
|---|---|
| Service Type | • Medicine Services and Procedures • Physical Medicine and Rehabilitation Evaluations |
| Common Place of Service | • 11 - Office • None |
| Common Modifiers | • None • GP - Services delivered under an outpatient physical therapy plan of care • KX - Requirements specified in the medical policy have been met |
| Complexity Level | Moderate |
National average reimbursement for CPT 97162 by major payers:
$92.81
$89.93
$91.35
$109.79
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
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CPT 97162 vs. Other Physical Medicine and Rehabilitation Evaluations Codes
The CPT 97162 code is part of the Medicine Services and Procedures services used for Physical Medicine and Rehabilitation Evaluations. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 97162 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 97161 | Low | Physical Therapy Evaluation: Low Complexity Re- Quiring These Components: A History With No Per- Sonal Factors And/Or Comorbidities That Impact The Plan Of Care; An Examination Of Body System(S)Using Standardized Tests And Measures Addressing 1-2 Elements From Any Of The Following: Body Structures And Functions Activity Limitations And/Or Participation Restrictions; A Clinical Presentation With Stable And/Or Uncomplicated Characteristics; And Clinical Decision Making |
| 97162 | Low | Physical Therapy Evaluation: Moderate Complexity Requiring These Components: A History Of Present Problem With 1-2 Personal Factors And/Or Comorbi- Dities That Impact The Plan Of Care; An Examina- Tion Of Body Systems Using Standardized Tests And Measures Addressing A Total Of 3 Or More Elements From Any Of The Following: Body Struc--Retures And Functions Activity Limitations And/Orparticipation Restrictions; An Evolving Clinical Presentation With Changing Characteristics; And |
| 97163 | Low | Physical Therapy Evaluation: High Complexity Requiring These Components: A History Of Present Problem With 3 Or More Personal Factors And/Or Comorbidities That Impact The Plan Of Care; An Examination Of Body Systems Using Standardized Tests And Measures Addressing A Total Of 4 Or Moreelements From Any Of The Following: Body Struc- Tures And Functions Activity Limitations And/Or Participation Restrictions; A Clinical Presenta- Tion With Unstable And Unpredictable Characteristi |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 97162. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 97162 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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Medicare Reimbursement Lookup Tool
Medicare localities are geographic regions used to adjust reimbursement rates based on local costs. Rates vary by locality to reflect differences in wages, rent, and other expenses. Sign up to see commercial rates (United/BCBS/Cigna/Aetna)
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| Year | Billing Code | Locality | Non-Facility Fee | Facility Fee |
|---|