PT Evaluation CPT Codes: 97161 vs 97162 vs 97163
PT eval CPT codes 97161, 97162 and 97163: how the four components set low, moderate or high complexity, when 97164 applies, live Medicare rates and NCCI rules.
On this page 9 sections
The PT evaluation CPT codes are 97161 (low complexity), 97162 (moderate) and 97163 (high), plus 97164 for a re-evaluation. The level comes from four components of the evaluation (history, examination, clinical presentation and clinical decision making), and every component has to support the level you bill. Minutes don't pick the level, and in the current Medicare release the three levels pay the same.
Key takeaways
- All four components must reach a level to bill it. One component at low complexity makes the evaluation 97161.
- Evaluations are untimed: one unit, whatever the length, and the evaluation minutes don't count toward the 8-minute rule.
- Medicare assigns 97161, 97162 and 97163 identical RVUs, so upcoding gains nothing from Medicare and still misstates the record. Some other payers do pay by level.
- One evaluation per episode of care, one evaluation or re-evaluation per day, and never an evaluation and a re-evaluation together.
- 97164 is for an unplanned, significant change in the patient's condition, not a routine progress check.
97161 vs 97162 vs 97163 at a glance
The code set describes each level by the same four components. In our words, from APTA's public summary of the codes:
| Component | 97161 low | 97162 moderate | 97163 high |
|---|---|---|---|
| History | No personal factors or comorbidities affecting the plan | One or two that affect the plan of care | Three or more that affect the plan of care |
| Examination | One or two elements addressed | Three or more elements | Four or more elements |
| Clinical presentation | Stable, uncomplicated | Evolving, with changing characteristics | Unstable, with unpredictable characteristics |
| Clinical decision making | Low complexity | Moderate complexity | High complexity |
Elements are body structures and functions, activity limitations and participation restrictions, counted across the regions and systems examined. Personal factors are things like age, coping style, social background or living situation that change how the patient's condition affects care; a factor only counts if it affects the plan. Decision making uses standardized assessment tools or measurable functional outcomes.
Pick the evaluation level
Answer for the evaluation in front of you. The flow stops as soon as one component caps the level.
Decide
History: how many personal factors or comorbidities change the plan of care?
What Medicare pays for each level
Code family
97161–97164
97163 pays $97.86 nationally in the office setting, from 2.93 total RVUs. Open 97163 →
CMS values the three evaluation levels identically: the same work, practice-expense and malpractice RVUs, so the same allowed amount in every locality. The re-evaluation pays less. Check it for your ZIP:
Medicare rate · 97162
PT evaluation, moderate complexity
- Work RVUs
- 1.54
- Total RVUs
- 2.93
- Global days
- XXX
National rate · 2026
$97.86
Office setting, before claim adjustments.
See every locality for 97162 →Billed by an NP, PA or therapist? →
Two consequences follow. With Medicare, choosing a higher level gains nothing and still puts an inaccurate code on the claim. With other payers it can matter: commercial plans, Medicare Advantage plans and workers' comp schedules set their own amounts, and some pay the levels differently. Many of those contracts are still priced as a percentage of Medicare, and many state workers' comp schedules start from Medicare's RVUs (California's physician fee schedule is RBRVS-based under Labor Code §5307.1), which is why clinics look the Medicare number up for every payer. Read the payer's schedule before assuming the levels pay the same.
Documenting the evaluation
Medicare's documentation rules for the evaluation are in the Benefit Policy Manual, ch. 15, §220.3.C. The evaluation and plan of care can be one document or two. A few rules catch billers out:
- Evaluation minutes are untimed. They're part of total treatment time, but "minutes of evaluation shall not be included in the minutes for timed codes reported in the treatment notes" (§220.3.C). Treatment on the same day is billed only for its own minutes.
- Only the therapist evaluates. PTAs "may not provide evaluative or assessment services" (§230.1.C). An evaluation furnished by a PTA isn't billable as an evaluation.
- Write the components down. Name the personal factors and comorbidities that affect the plan, the elements tested and the tools used, the presentation, and the reasoning. A complexity level with no support in the note is the level a reviewer will lower.
- The plan still needs certification. A physician or NPP signs the plan within 30 days of the first treatment day (§220.1.3); see physical therapy CPT codes for the written-order exception.
When to bill 97164, the re-evaluation
Medicare pays a re-evaluation when the clinician's assessment shows a significant improvement, decline or other change in the patient's condition or function that the plan of care didn't anticipate (§220, definitions). The manual lists the triggers: new clinical findings, a significant change in condition, or failure to respond to the treatment in the plan. A re-evaluation before a planned discharge can also be appropriate.
It isn't for routine reassessment. "Continuous assessment of the patient's progress is a component of ongoing therapy services and is not payable as a re-evaluation" (§220.3.C), and progress reports, due at least once every 10 treatment days, aren't re-evaluations either. Under NCCI, re-evaluations "shall not be routinely reported during a planned course" of therapy; some treatment codes are paired with 97164 in PTP edits, and when a medically necessary re-evaluation happens on a treatment day, the modifier is 59 or XU on 97164 (NCCI Policy Manual, ch. XI, §P.3).
NCCI and MUE rules for PT evaluations
| Rule | Source |
|---|---|
| One evaluation or re-evaluation per physical therapist per date | NCCI Policy Manual, ch. XI, §P.1 |
| 97161–97163 at most one unit per episode of care; 97164 at most one per date | NCCI Policy Manual, ch. XI, §V.21 |
| MUE of 1 unit per day for each of 97161, 97162, 97163 and 97164 | Practitioner MUE table, Oct 1, 2026 |
| Evaluation + re-evaluation the same day: indicator 0, never paid together | PTP edits v32.3 (97161/97162/97163 with 97164) |
| Two evaluation levels the same day: indicator 0 | PTP edits v32.3 |
| Evaluation + 97750 physical performance test: indicator 0 | PTP edits v32.3; ch. XI, §P.8 |
| Evaluation + 97110, 97112, 97140 or 97530: no edit | PTP edits v32.3 |
So an evaluation and treatment on the same day are both billable without a modifier: one unit of the evaluation, plus timed units counted from the treatment minutes alone. A PT and an OT evaluation on the same day for the same patient are both billable only when two different practitioners perform them (ch. XI, §P.1).
8-minute rule
Timed minutes → billable units
- 97110Therapeutic exercise, one-on-one, each 15 minutesmin
- 97140Manual therapy, one or more regions, each 15 minutesmin
Medicare: 25 timed minutes
2 units
97110 × 1 · 97140 × 1 · about $56.78 nationally before therapy reductions
- Per-code method
- 2 units
- Difference
- Same
● Extra unit assigned from leftover minutes, to the code with the most leftover time.
Common mistakes
- Leveling by time. The code set lists a typical face-to-face time for each level, but the components select the level. A long evaluation can still be 97161.
- Counting factors that don't change the plan. Age or a comorbidity only counts when it affects the plan of care, and the note should say how.
- Billing a re-evaluation with an initial evaluation, or two evaluations on one day. Both are indicator-0 edits.
- Adding the evaluation minutes to the timed total. It inflates units on every treatment code that day.
- A PTA "updating" the evaluation. Only the therapist can evaluate or re-evaluate.
FAQ
What is the CPT code for a PT evaluation?
97161 for a low-complexity evaluation, 97162 for moderate complexity and 97163 for high complexity. A re-evaluation is 97164. Each is billed as one unit with the GP modifier.
What is the difference between 97161, 97162 and 97163?
The complexity of four components: how many personal factors and comorbidities affect the plan, how many elements the exam addressed, whether the presentation is stable, evolving or unstable, and how complex the decision making was. All four must support the level billed.
Does 97163 pay more than 97161?
Not from Medicare. CMS assigns the three evaluation levels identical RVUs, so the national and local Medicare amounts are the same. Other payers set their own rates, and some do pay more for higher levels.
Can you bill an evaluation and treatment on the same day?
Yes. There's no NCCI edit between the evaluation codes and timed codes such as 97110, 97140 or 97530. Bill one unit of the evaluation and count timed units from the treatment minutes only. The exception is 97750, which isn't separately payable with an evaluation by the same practitioner.
How often can you bill 97164?
When the documentation shows a significant, unanticipated change, new clinical findings or a failure to respond to treatment, and no more than one unit per day. Medicare doesn't pay re-evaluations on a fixed schedule.
Is the PT evaluation code timed?
No. 97161–97164 are untimed: one unit regardless of length. Their minutes count toward total treatment time but not toward the timed minutes used for the 8-minute rule.
Keep reading
- Physical therapy CPT codes: the hub for every PT code, rule and tool on FeeBase.
- 97110 vs 97530 and 97110 vs 97112 for the treatment codes billed after the evaluation.
- 8-minute rule calculator for timed units on evaluation days.
- Medicare physical therapy fee schedule for the evaluation codes at your locality.
- Modifiers: GP, 59, XU, KX.
- Codes in this guide: 97161 97162 97163 97164 97750 97110 97140
Sources: Medicare Benefit Policy Manual, Pub. 100-02, ch. 15, §220 (definitions), §220.1.3, §220.3.C and §230.1.C; Medicare NCCI Policy Manual (2026), ch. XI, §P.1, §P.3, §P.8 and §V.21; CMS NCCI practitioner PTP edits v32.3 and practitioner MUE table, effective October 1, 2026; APTA Physical Therapy Evaluation Reference Table (2020); Cal. Labor Code §5307.1. Rates from the CMS release shown on each widget. Verified October 7, 2026.
Related tools and guides
Therapy billingCPT Codes for Physical Therapy: Medicare Guide (2026)
CPT codes and physical therapy billing for Medicare: evaluations 97161–97164, timed codes, the 8-minute rule, GP, CQ and KX, code comparisons and live rates.
Therapy billing97110 vs 97530: Therapeutic Exercise vs Activities
97110 vs 97530: exercise targets one impairment, therapeutic activities a functional task. What the note needs, live Medicare rates, NCCI and billing both.
Therapy billing97110 vs 97112: Therapeutic Exercise vs Neuromuscular Re-ed
97110 vs 97112: exercise builds strength and motion, neuromuscular re-education retrains balance and control. Documentation, Medicare rates, units and MUEs.
