$94.33
97161 is for a low-complexity initial physical therapy evaluation. Choose 97163 only when the documented presentation and decision making support high complexity.
On this page
CMS RVU26D · Effective 2026-10-01
97163 PT evaluation Medicare reimbursement rates in Indiana
Report this evaluation when a physical therapist assesses a patient with complex needs, an unstable presentation, and high-complexity clinical decision making. Compare 97163 office and facility rates across CMS payment localities in Indiana.
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.
What does Medicare pay for 97163 in Indiana?
Indiana 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.
Office / nonfacility
$94.33
1 of 1 localities have a supported rate.
Payment area: Indiana
One mapped payment locality.
Facility setting
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
About 97163: High-complexity physical therapy evaluation
Report this evaluation when a physical therapist assesses a patient with complex needs, an unstable presentation, and high-complexity clinical decision making.
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.
CMS billing rules for 97163
- Professional and technical components
- Therapy service: the professional component modifier does not apply.
- Multiple procedures
- Therapy multiple procedure payment reduction: practice expense is reduced for the second and later therapy units on the same day.
Where the value comes from
- Work RVU1.54 · 53%
- Practice expense (office) RVU1.38 · 47%
- Malpractice RVU0.01 · 0%
284.1K
Medicare services in 2024 · #323 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.
97163 compared with similar codes
Office rates for Indiana, from the same CMS release.
$94.33
97162 represents moderate-complexity initial physical therapy evaluation; 97163 represents high complexity with an unstable, unpredictable presentation.
$64.74
97164 is a re-evaluation of an established plan of care. Use 97163 for an initial evaluation when high-complexity criteria are supported.
$96.81
97167 is a high-complexity occupational therapy evaluation. Use 97163 when the service is a physical therapy evaluation.
Compare 97163 by payment locality
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
Indiana →
Office / nonfacility
$94.33
Facility
Unavailable
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How this local rate is calculated
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 97163 in Indiana.
PPRRVU2026_Oct_nonQPP.csv
12,879
- Code
- 97163
- Physician work
- 1.54
- Practice expense
- 1.38
- Malpractice
- 0.01
GPCI2026.csv
52
- Locality
- Indiana
- Physician work
- 1.000
- Practice expense
- 0.927
- Malpractice
- 0.486
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 1.54 | × 1.000 | 1.5400 |
| Practice expense | 1.38 | × 0.927 | 1.2793 |
| Malpractice | 0.01 | × 0.486 | 0.0049 |
| Total RVUs | 2.8241 | ||
| Conversion factor | × 33.4009 | ||
Office / nonfacility rate, Indiana$94.33
Explore RVUs, geographic factors and the full formula
Office / nonfacility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 1.54 | 1 |
| Practice expense | 1.38 | 0.927 |
| Malpractice | 0.01 | 0.486 |
(1.54 × 1 + 1.38 × 0.927 + 0.01 × 0.486) × $33.4009 = $94.33
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.
97163 billing questions
When should 97163 be chosen instead of 97162?
Use 97163 when the documented evaluation supports high-complexity decision making and an unstable, unpredictable presentation. A longer visit alone does not distinguish it from the moderate-complexity evaluation.
Is 97163 billed in timed units?
No. It is reported as one untimed evaluation unit; the typical 45-minute service time is not a timed-unit threshold.
What documentation supports high complexity?
Document the relevant personal factors or comorbidities, examination findings across the assessed functional areas, the unstable or unpredictable presentation, and how those findings informed the plan of care.
Can a professional-component modifier be appended?
No. CMS identifies 97163 as a therapy service for which the professional-component modifier does not apply.
How does the same-day therapy reduction affect payment?
CMS reduces practice expense for the second and later therapy units furnished on the same day. The evaluation itself remains one untimed unit.
When is 97164 more appropriate?
Use 97164 for a physical therapy re-evaluation of an established plan of care, rather than for the initial high-complexity evaluation represented by 97163.
Where these rates come from
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.
12,87697158,,Grp adapt bhv tx by phy/qhp,C,,0.00,0.00,,0.00,,0.00,0.00,0.00,0,XXX,0.00,0.00,0.00,0,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
12,87797161,,Pt eval low complex 20 min,A,,1.54,1.38,,1.38,NA,0.01,2.93,2.93,7,XXX,0.00,0.00,0.00,5,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
12,87897162,,Pt eval mod complex 30 min,A,,1.54,1.38,,1.38,NA,0.01,2.93,2.93,7,XXX,0.00,0.00,0.00,5,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
12,87997163,,Pt eval high complex 45 min,A,,1.54,1.38,,1.38,NA,0.01,2.93,2.93,7,XXX,0.00,0.00,0.00,5,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
12,88097164,,Pt re-eval est plan care,A,,0.96,1.05,,1.05,NA,0.01,2.02,2.02,7,XXX,0.00,0.00,0.00,5,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
12,88197165,,Ot eval low complex 30 min,A,,1.54,1.46,,1.46,NA,0.01,3.01,3.01,7,XXX,0.00,0.00,0.00,5,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
12,88297166,,Ot eval mod complex 45 min,A,,1.54,1.46,,1.46,NA,0.01,3.01,3.01,7,XXX,0.00,0.00,0.00,5,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
4906102,IL,12,EAST ST. LOUIS,1.000,0.920,2.014
5006102,IL,15,SUBURBAN CHICAGO,1.007,1.027,1.772
5106102,IL,99,REST OF ILLINOIS,1.000,0.913,1.563
5208102,IN,00,INDIANA,1.000,0.927,0.486
5305102,IA,00,IOWA,1.000,0.915,0.397
5405202,KS,00,KANSAS,1.000,0.904,0.504
5515102,KY,00,KENTUCKY,1.000,0.889,0.915