CPT 97169 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 • 50 - Federally Qualified Health Center |
| Common Modifiers | • None • 59 - Distinct Procedural Service • 25 - Significant, separately identifiable E/M service same day |
| Complexity Level | Moderate |
National average reimbursement for CPT 97169 by major payers:
$55.34
$57.41
$41.87
$71.67
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
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CPT 97169 vs. Other Physical Medicine and Rehabilitation Evaluations Codes
The CPT 97169 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 97169 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 |
|---|---|---|
| 97168 | Low | Re-Evaluation Of Occupational Therapy Established Plan Of Care Requiring These Components: An Assessment Of Changes In Patient Functional Or Medical Status With Revised Plan Of Care; An Update To The Initial Occupational Profile To Reflect Changes In Condition Or Environment That Affect Future Interventions And/Or Goals; And A Revised Plan Of Care. A Formal Reevaluation Is Performed When There Is A Documented Change In Functional Status Or A Significant Change To |
| 97169 | Low | Athletic Training Evaluation Low Complexity Requiring These Components: A History And Phy- Sicalactivity Profile With No Comorbidities That Affect Physical Activity; An Examination Of Af- Fected Body Area And Other Symptomatic Or Related Systems Addressing 1-2 Elements From Any Of The Following: Body Structures Physical Activity And/Or Participation Deficiencies; And Clinical Decision Making Low Complexity Using Standardized Patient Assessment Instrument |
| 97170 | Low | Athletic Training Evaluation Moderate Complexity Requiring These Components: A Medical History And Physical Activity Profile With 1-2 Comorbi- Dities That Affect Physical Activity; An Examina- Tion Of Affected Body Area And Other Symptomatic Or Related Systems Addressing A Total Of 3 Or Moreelements From Any Of The Following: Body Struc- Tures Physical Activity And/Or Participation Deficiencies; And Clinical Decision Making Of Mo- Deratecomplexity Using Standardized Patient Asses |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 97169. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 97169 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 |
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