CPT 97172 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 • 20 - Urgent Care Facility |
| Common Modifiers | • None • GP - Services delivered under an outpatient physical therapy plan of care • 25 - Significant, separately identifiable E/M service same day • 59 - Distinct Procedural Service |
| Complexity Level | Moderate |
National average reimbursement for CPT 97172 by major payers:
$35.96
$28.73
$23.48
$40.47
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
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CPT 97172 vs. Other Physical Medicine and Rehabilitation Evaluations Codes
The CPT 97172 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 97172 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 |
|---|---|---|
| 97171 | Low | Athletic Training Evaluation High Complexity Requiring These Components: A Medical History And Physical Activity Profile With 3 Or More Comorbidities That Affect Physical Activity; A Comprehensive Examination Of Body Systems Using Standardized Tests And Measures Addressing A Total Of 4 Or More Elements From Any Of The Following: Body Structures Physical Activity And/Or Participation Deficiencies; Clinical Presentation With |
| 97172 | Low | Re-Evaluation Of Athletic Training Established Plan Of Care Requiring These Components: An Assessment Of Patients Current Functional Status When There Is A Documented Change ; And A Revised Plan Of Care Using Standardized Patient Assessmentinstrument And/Or Measurable Assessment Of Func- Tional Outcome With An Update In Management Options Goals And Interventions. Typically 20minutes Are Spent Face-To-Face With The Patient And/Or Family |
| 97530 | Low | Therapeutic Activities Direct (One-On-One) Patient Contact (Use Of Dynamic Activities To Improve Functional Performance) Each 15 Minutes (Revised 01/01/13) |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 97172. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 97172 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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