Billing code 97161: PT evaluationMedicare rate & RVUs in Vermont
Initial physical therapy evaluation reported when the history, examination, stable presentation, and clinical decision making support low complexity.
Medicare pays $97.24 for 97161 in the office in Vermont (Vermont). 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 97161 covers
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.
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.
97161 in Vermont
| Payment locality | Office | Facility |
|---|---|---|
| Vermont | $97.24 | Unavailable |
How the 97161 rate is calculated
Each of 97161’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 · 97161
RVUs × geographic indexes × conversion factor
Work1.54
1.54 RVUs× 1.000 GPCI
Practice expense1.38
1.38 RVUs× 1.000 GPCI
Malpractice0.01
0.01 RVUs× 1.000 GPCI
Adjusted RVUs
2.9300
Conversion factor
$33.4009
Medicare rate
$97.86
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 97161
The CMS indicators that decide how 97161 is paid alongside other services.
CMS payment indicators · 97161
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
97161 without CQ · national office
$97.86
PT evaluation
97161-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.
97161 compared with similar codes
Compare codes · National
4 codes, side by side
How to choose
- 97162PT evaluation
- 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.
- 97164PT re-evaluation
- 97164 reassesses a patient under an established PT plan of care. 97161 is an initial low-complexity evaluation used to establish a plan.
- 97165OT evaluation
- 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.
97161 billing questions
How do I choose between 97161, 97162, and 97163?
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.
Do I bill time units for 97161?
No. Report one unit for the evaluation. The approximately 20-minute face-to-face time is typical, not a minimum that must be met.
Can treatment be billed on the same day as the evaluation?
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.
Which modifier is used for a Medicare physical therapy evaluation?
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.
When should 97164 be used instead?
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.
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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