CMS RVU26D · Effective 2026-10-01
Initial physical therapy evaluation reported when the history, examination, stable presentation, and clinical decision making support low complexity. Compare 97161 office and facility rates across CMS payment localities in Delaware.
Amounts below use the non-QP conversion factor for participating physicians. These are base physician payments before claim-level adjustments, not patient costs or total hospital charges.
Delaware has 1 payment locality in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the payment area shown below, using the same CMS release.
$97.53
1 of 1 localities have a supported rate.
Payment area: Delaware
One mapped payment locality.
No supported rate
These are locality ranges, not averages or address-specific quotes. A facility-setting amount covers the physician service; it does not include a hospital’s separate bill. Choose a locality below to inspect its calculation, compare other payment areas, or price a percentage of Medicare.
Physical therapy
Initial physical therapy evaluation reported when the history, examination, stable presentation, and clinical decision making support low complexity.
A physical therapist uses this initial evaluation to assess movement, functional limitations, and rehabilitation needs in private practice, an outpatient clinic, or a hospital outpatient department. Low complexity calls for a history without personal factors or comorbidities affecting the plan, examination of one or two elements, a stable presentation, and low-complexity clinical decision making supported by standardized assessment tools or measurable functional outcomes. An adult with a straightforward musculoskeletal complaint may fit when the documented findings meet these criteria. The therapist uses the findings to establish functional goals and a treatment plan.
Report one unit for the evaluation; approximately 20 minutes face to face is typical, not a billing threshold. Select the level from the documented history, examined elements, presentation, and decision making rather than time or one component alone. Record the findings, assessment measures, goals, and plan of care for physician or nonphysician practitioner certification. Medicare physical therapy claims use modifier GP. This therapy service is billed without separate professional and technical components, so modifier 26 is inappropriate. When multiple therapy units are billed on the same day, the therapy multiple procedure payment reduction reduces practice expense for the second and later units.
1.7M
Medicare services in 2024 · #90 by national volume
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.
Office rates for Delaware, from the same CMS release.
97162 describes a moderate-complexity PT evaluation, generally involving one or two personal factors or comorbidities affecting care, an exam of at least three elements, and an evolving presentation. Choose 97161 when the documented components support low complexity.
97164 reassesses a patient under an established PT plan of care. 97161 is an initial low-complexity evaluation used to establish a plan.
97165 is a low-complexity occupational therapy evaluation under an OT plan of care, identified by modifier GO. 97161 is a physical therapy evaluation under a PT plan of care, identified by GP.
Find the payment area for your service address, then open its rate page for calculation inputs, release history and the percentage-of-Medicare tool. A city may cross payment-area boundaries; the ZIP lookup above helps resolve the location.
1 of 1 payment localities
Office / nonfacility
$97.53
Facility
Unavailable
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Each RVU component is multiplied by its own geographic practice cost index (GPCI). The three adjusted components are added, then multiplied by the conversion factor. These are the inputs used for 97161 in Delaware.
PPRRVU2026_Oct_nonQPP.csv
12,877
GPCI2026.csv
40
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 1.54 | × 1.005 | 1.5477 |
| Practice expense | 1.38 | × 0.988 | 1.3634 |
| Malpractice | 0.01 | × 0.899 | 0.0090 |
| Total RVUs | 2.9201 | ||
| Conversion factor | × 33.4009 | ||
Office / nonfacility rate, Delaware$97.53
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 1.54 | 1.005 |
| Practice expense | 1.38 | 0.988 |
| Malpractice | 0.01 | 0.899 |
(1.54 × 1.005 + 1.38 × 0.988 + 0.01 × 0.899) × $33.4009 = $97.53
The office and facility calculations use their respective practice-expense RVUs. The facility amount here is the physician fee, not a separate hospital or facility bill.
Compare the documented history, examination, clinical presentation, and decision making with the requirements for each level. Do not choose a level from time or one component alone; 97162 generally involves personal factors or comorbidities affecting care, a broader exam, and an evolving presentation.
No. Report one unit for the evaluation. The approximately 20-minute face-to-face time is typical, not a minimum that must be met.
Yes. Therapeutic exercise or manual therapy can be reported separately when the treatment is distinct from the evaluation and its time is documented. The therapy multiple procedure payment reduction affects practice expense for the second and later therapy units that day.
Use GP to identify the service as furnished under a physical therapy plan of care. Do not use modifier 26; this therapy service is not divided into separately billed professional and technical components.
Use 97164 to re-evaluate a patient under an established physical therapy plan of care, such as after a significant change in status. Use an initial evaluation code when a new episode requires an initial assessment and plan.
FeeBase calculates base physician payments from CMS work, practice-expense, and malpractice RVUs, adjusted by each locality’s geographic indices and the applicable conversion factor. Unavailable or separately priced services are labeled rather than assigned a made-up amount.
Source: RVU26D. Effective 2026-10-01 through the day before 2027-01-01.
