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See a sample rate comparisonCPT 97164 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 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
| 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 59 - Distinct Procedural Service |
| Complexity Level | Low |
| Medicare Fee Schedule | $67.47 national non-facility rate (2026) · View Medicare rates for 97164 |
| Medicaid Fee Schedule | $54.67 median of the 7 states in the free preview · View Medicaid rates for 97164 |
National average reimbursement for CPT 97164 by major payers:
$71.84
$61.44
$62.68
$77.64
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CPT 97164
5 of 25 sample ratesHigher to lower in this preview
James Harding
Memorial Developmental Chemo Group
$238.49Published rateDimitria Papadopoulos
Bellmore Dermatology PLLC
$62.88Published rateKereme Manners
New York City Health And Hospitals Corporation
$53.93Published rateHenry Roman
Essen Medical Associates, P.C.
$47.31Published rateJohn Bennett
University Of Rochester
$42.00Published rate
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See a sample payer proposalCPT 97164 vs. Other Physical Medicine and Rehabilitation Evaluations Codes
The CPT 97164 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 97164 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 |
|---|---|---|
| 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 |
| 97165-CPT | Low | Ot Eval Low Complex 30 Min, Occupational Therapy Evaluation Low Complexity Requiring These Components An Occupational Profile And Medical And Therapy History Which Includes A Brief History Including Review Of Medical And Or Therapy Records Relating To The Presenting Problem An Assessment S That Identifies 1 3 Performance Deficits Ie Relating To Physical Cognitive Or Psychosocial Skills That Result In Activity Limitations And Or Participation Restrictions And Clinical Decision Making Of Low Complexity Which Includes An Analysis Of The Occupational Profile Analysis Of Data From Problem Focused Assessment S And Consideration Of A Limited Number Of Treatment Options Patient Presents With No Comorbidities That Affect Occupational Performance Modification Of Tasks Or Assistance Eg Physical Or Verbal With Assessment S Is Not Necessary To Enable Completion Of Evaluation Component Typically 30 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 97164. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 97164 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 find out the cost of a specific medical procedure, especially one based on a CPT code and your specific location, you can utilize tools designed for price transparency. We recommend checking Payerprice, which offers a fee schedule lookup tool allowing you to search for costs using CPT codes and specific geographical locations. This can help you understand potential charges before your service.
A CPT (Current Procedural Terminology) code is a standardized five-digit code used by healthcare professionals to report medical, surgical, and diagnostic services to entities like insurers. It is crucial for understanding costs because it precisely identifies the specific service you received or will receive, allowing you to look up expected charges, compare prices, and understand what your insurance might cover for that particular service.
To understand what your insurance will cover, it's best to contact your insurance provider directly. They can provide details specific to your plan, including deductibles, co-pays, co-insurance, and covered services. However, to understand the potential underlying cost of a service before contacting your insurer, you can use Payerprice's fee schedule lookup tool with the relevant CPT code and location, which can then help you have a more informed discussion with your insurance company.
A 'charge' (or 'list price') is the amount a healthcare provider initially bills for a service, often significantly higher than what is actually paid. A 'negotiated rate' (or 'allowed amount') is the discounted price that a healthcare provider and an insurance company have agreed upon for a specific service. Patients with insurance typically pay based on the negotiated rate, not the initial charge, plus any applicable deductibles, co-pays, or co-insurance.
For detailed information on fee schedules, especially those specific to CPT codes and your location, you can use specialized price transparency tools. We recommend Payerprice, which offers a comprehensive fee schedule lookup tool. You can input a CPT code and your specific location to find relevant pricing information.
To compare prices for healthcare services in your area, you can utilize price transparency tools that provide access to fee schedules. Payerprice offers a valuable fee schedule lookup tool where you can search by CPT code and specific location to find and compare the costs of various medical procedures and services, helping you make more informed decisions.