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See a sample rate comparisonCPT 97163 Fee Schedule
Last Verified: October 2026
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.
Pt Eval High Complex 45 Min, 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 More Elements From Any Of The Following Body Structures And Functions Activity Limitations And Or Participation Restrictions A Clinical Presentation With Unstable And Unpredictable Characteristics And Clinical Decision Making Of High Complexity Using Standardized Patient Assessment Instrument And Or Measurable Assessment Of Functional Outcome Typically 45 Minutes Are Spent Face To Face With The Patient And Or Family
| Key Fact | Detail |
|---|---|
| Service Type | Medicine Services and Procedures Physical Medicine and Rehabilitation Evaluations |
| Common Place of Service | 11 - Office |
| Common Modifiers | GP - Services delivered under an outpatient physical therapy plan of care KX - Requirements specified in the medical policy have been met |
| Complexity Level | Low |
| Medicare Fee Schedule | $97.87 national non-facility rate (2026) · View Medicare rates for 97163 |
| Medicaid Fee Schedule | $79.56 median of the 7 states in the free preview · View Medicaid rates for 97163 |
National average reimbursement for CPT 97163 by major payers:
$93.46
$89.93
$90.85
$108.85
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CPT 97163
5 of 25 sample ratesHigher to lower in this preview
Rhonda Bellavia
$243.27Published rateLauren Boggs
Orthoconnecticut, PC
$91.02Published rateCurtis Becker
Sports Medicine & Orthopaedic Center, Inc.
$85.91Published rateAndrea Moehringer
Slocum Dickson Medical Group PLLC
$84.00Published rateJill Cunningham
Slocum Dickson Medical Group PLLC
$76.55Published rate
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See a sample payer proposalCPT 97163 vs. Other Physical Medicine and Rehabilitation Evaluations Codes
The CPT 97163 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 97163 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 |
|---|---|---|
| 97162-CPT | Low | Pt Eval Mod Complex 30 Min, Physical Therapy Evaluation Moderate Complexity Requiring These Components A History Of Present Problem With 1 2 Personal Factors And Or Comorbidities That Impact The Plan Of Care An Examination Of Body Systems Using Standardized Tests And Measures In Addressing A Total Of 3 Or More Elements From Any Of The Following Body Structures And Functions Activity Limitations And Or Participation Restrictions An Evolving Clinical Presentation With Changing Characteristics And Clinical Decision Making Of Moderate Complexity Using Standardized Patient Assessment Instrument And Or Measurable Assessment Of Functional Outcome Typically 30 Minutes Are Spent Face To Face With The Patient And Or Family |
| 97163-CPT | Low | Pt Eval High Complex 45 Min, 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 More Elements From Any Of The Following Body Structures And Functions Activity Limitations And Or Participation Restrictions A Clinical Presentation With Unstable And Unpredictable Characteristics And Clinical Decision Making Of High Complexity Using Standardized Patient Assessment Instrument And Or Measurable Assessment Of Functional Outcome Typically 45 Minutes Are Spent Face To Face With The Patient And Or Family |
| 97164-CPT | Low | Pt Re Eval Est Plan Care, Re Evaluation Of Physical Therapy Established Plan Of Care Requiring These Components An Examination Including A Review Of History And Use Of Standardized Tests And Measures Is Required And Revised Plan Of Care Using A Standardized Patient Assessment Instrument And Or Measurable Assessment Of Functional Outcome Typically 20 Minutes Are Spent Face To Face With The Patient And Or Family |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 97163. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 97163 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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Frequently Asked Questions
To get specific cost estimates based on a CPT code and your location, it is best to use a specialized tool. We recommend using Payerprice's fee schedule lookup tool, which allows you to search with a CPT code and your specific location to get detailed pricing information relevant to your situation.
A CPT (Current Procedural Terminology) code is a five-digit numerical code used by healthcare providers to describe medical, surgical, and diagnostic services. These codes are crucial for medical billing and are used by insurers and payers to determine the amount they will pay for a service. When looking up costs, using the correct CPT code ensures you're comparing prices for the exact same service, providing a more accurate estimate.
To compare prices for specific services, you can utilize tools designed for this purpose. Payerprice offers a fee schedule lookup tool where you can enter a CPT code and your location to see how prices may vary among providers. This helps you make informed decisions about your healthcare choices.
While knowing the CPT code provides the most accurate search results, you can often ask your doctor, specialist, or the facility providing the service for the CPT code associated with the procedure or service you need. Once you have it, you can use tools like Payerprice's fee schedule lookup tool to get a more precise estimate.
Payerprice offers a fee schedule lookup tool specifically designed for users to search with a CPT code and a specific location to find detailed pricing information. This tool is geared towards consumer access and ease of use for individual situations, providing a direct way to understand potential costs for your specific healthcare needs.