CPT code 97163: PT evaluation, high complexity2026 Medicare rate & RVUs

Medicare pays $97.86 for 97163 nationally in the office. Local office rates run $91.20–$126.43.

Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.

What 97163 covers

A physical therapist uses this code for an initial evaluation requiring high-complexity decision making, typically in an outpatient rehabilitation setting. The evaluation may involve a patient with multiple personal factors or comorbidities affecting the plan of care, findings across several body systems or functional areas, and an unstable, unpredictable presentation. The therapist integrates the history, examination, and assessment findings to establish the rehabilitation plan. The service typically takes 45 minutes, but it is reported as one untimed evaluation unit rather than billed in timed increments.

Select this level when the documented history, examination, clinical presentation, and decision making support high complexity—not simply because the visit lasted a particular amount of time. Record the relevant personal factors or comorbidities, examination findings, functional effects, instability or unpredictability, and reasoning behind the plan. CMS treats this as a therapy service, so a professional-component modifier does not apply. When multiple therapy units are furnished on the same day, practice expense is reduced for the second and later units.

This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.

Where 97163 pays more and less

The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.

109 of 109 payment localities

97163 rates by state

Office rate range in each state. Select a state to see its payment localities.

How the 97163 rate is calculated

Each of 97163’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.

Payment rules and modifiers for 97163

The CMS indicators that decide how 97163 is paid alongside other services.

What modifiers do to the payment

97163 compared with similar codes

How to choose

97161PT evaluationLow complexity, typically 20 minutes

97161 is for a low-complexity initial physical therapy evaluation. Choose 97163 only when the documented presentation and decision making support high complexity.

97162PT evaluationModerate complexity

97162 represents moderate-complexity initial physical therapy evaluation; 97163 represents high complexity with an unstable, unpredictable presentation.

97164PT re-evaluationEstablished plan of care

97164 is a re-evaluation of an established plan of care. Use 97163 for an initial evaluation when high-complexity criteria are supported.

97167OT evaluationHigh complexity

97167 is a high-complexity occupational therapy evaluation. Use 97163 when the service is a physical therapy evaluation.

Codes related to 97163

Related codes aren’t interchangeable: bill the code that matches the service performed.

Where these rates come from

FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.

CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027

Open CMS sourceHow we calculate rates