Billing code 97163: PT evaluationMedicare rate & RVUs in Utah
Report this evaluation when a physical therapist assesses a patient with complex needs, an unstable presentation, and high-complexity clinical decision making.
Medicare pays $95.06 for 97163 in the office in Utah (Utah). Which amount applies depends on the service address.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 9 sections
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.
97163 in Utah
| Payment locality | Office | Facility |
|---|---|---|
| Utah | $95.06 | Unavailable |
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.
How the rate is built · 97163
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 1.54Practice expense 1.38Malpractice 0.01
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 97163
The CMS indicators that decide how 97163 is paid alongside other services.
CMS payment indicators · 97163
PT evaluation
| Rule | CMS value | What it means |
|---|---|---|
| Global period | XXX | The global surgery concept doesn’t apply. |
| Multiple procedures | 5 | Therapy reduction: practice expense of the second and later units is reduced. |
| Bilateral (modifier 50) | 0 | The 150% bilateral adjustment doesn’t apply. |
| Assistant at surgery (80/81/82/AS) | 0 | Not paid without supporting documentation. |
| Co-surgeons (62) | 0 | Not permitted. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 7 | Therapy service: the split doesn’t apply. |
What modifiers do to the payment
Modifier CQ · payment effect
With and without the modifier
97163 without CQ · national office
$97.86
PT evaluation
97163-CQ · Allowed amount unchanged
$97.86
Medicare cuts its own payment by 15% after the patient’s 20% coinsurance; the allowed amount stays the same. On $100 allowed: $20 coinsurance, then Medicare pays $68 instead of $80.
97163 compared with similar codes
Compare codes
97163 vs 97161 vs 97162 vs 97164 vs 97167: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 97161PT evaluation
- 97161 is for a low-complexity initial physical therapy evaluation. Choose 97163 only when the documented presentation and decision making support high complexity.
- 97162PT evaluation
- 97162 represents moderate-complexity initial physical therapy evaluation; 97163 represents high complexity with an unstable, unpredictable presentation.
- 97164PT re-evaluation
- 97164 is a re-evaluation of an established plan of care. Use 97163 for an initial evaluation when high-complexity criteria are supported.
- 97167OT evaluation
- 97167 is a high-complexity occupational therapy evaluation. Use 97163 when the service is a physical therapy evaluation.
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 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
Show the CMS file lines behind this rate
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