Billing code 97162: PT evaluationMedicare rate & RVUs in Washington
Initial physical therapy evaluation of moderate complexity, reported once when a therapist assesses a new episode of care with an evolving presentation and develops a plan of care.
Medicare pays $100.90–$110.84 for 97162 in the office in Washington, from Rest Of Washington to Seattle (King Cnty). 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 97162 covers
A physical therapist performs this evaluation at the start of a treatment episode, often in a private practice or outpatient clinic. Referrals after a fall, joint replacement, or lumbar strain do not alone establish complexity. The moderate level requires one or two personal factors or comorbidities affecting the plan, examination of at least three elements of body structures and functions, activity limitations, or participation restrictions, an evolving presentation, and moderate clinical decision making supported by a standardized assessment or measurable functional outcome. Face-to-face time is typically about 30 minutes.
Report 97162 once per evaluation, not in 15-minute units; typical time is not a billing threshold. Document how the history, examination, presentation, and decision making support moderate complexity, including relevant comorbidities, findings, outcome measures, goals, and the plan of care. Medicare physical therapy claims use the GP modifier; the professional component modifier 26 is not used for this therapy service. Under Medicare’s therapy multiple procedure payment reduction, the therapy unit with the highest practice expense receives unreduced practice expense; practice expense is reduced for second and later therapy units on the same day.
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.
Where 97162 pays more and less in Washington
| Payment locality | Office | Facility |
|---|---|---|
| Rest Of Washington | $100.90 | Unavailable |
| Seattle (King Cnty) | $110.84 | Unavailable |
How the 97162 rate is calculated
Each of 97162’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 · 97162
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 97162
The CMS indicators that decide how 97162 is paid alongside other services.
CMS payment indicators · 97162
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
97162 without CQ · national office
$97.86
PT evaluation
97162-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.
97162 compared with similar codes
Compare codes · National
5 codes, side by side
How to choose
- 97161PT evaluation
- Choose 97161 when the documented evaluation supports low complexity: a stable presentation, no personal factors or comorbidities affecting the plan, examination of one or two elements, and low-complexity decision making.
- 97163PT evaluation
- 97163 requires an unstable, unpredictable presentation, three or more complicating personal factors or comorbidities, examination of four or more elements, and high-complexity decision making.
- 97164PT re-evaluation
- 97164 applies when a patient under an established PT plan of care needs formal reassessment because of a change in status; 97162 is an initial evaluation for a treatment episode.
- 97166OT evaluation
- 97166 is a moderate-complexity occupational therapy evaluation under an OT plan of care, identified on Medicare claims by the GO modifier. 97162 is the corresponding PT evaluation under a GP plan of care.
97162 billing questions
How is moderate complexity distinguished from low complexity?
Moderate complexity requires one or two personal factors or comorbidities affecting the plan, at least three examined elements, an evolving presentation, and moderate decision making supported by a standardized assessment or measurable functional outcome. Use 97161 when the documented evaluation supports the low-complexity level instead.
Does the 30 minutes have to be met to bill 97162?
No. Thirty minutes is typical face-to-face time, not a billing threshold. Select the level from the evaluation components and report one unit for the evaluation.
Can treatment codes be billed on the same day as the evaluation?
Yes. Therapeutic exercise or manual therapy performed in addition to the evaluation may be separately reported when supported by documentation. Evaluation time is not counted toward timed treatment units.
Can 97162 and a re-evaluation be billed together?
97164 is for reassessing a patient under an established PT plan of care, not for the initial evaluation of that same treatment episode. Do not report both for the same evaluation.
What modifier does Medicare expect on this code?
The GP modifier identifies a service under a physical therapy plan of care. The professional component modifier 26 is not used for this therapy evaluation.
How does the multiple procedure reduction affect this evaluation?
When multiple therapy units are billed on the same day, the unit with the highest practice expense receives unreduced practice expense; practice expense is reduced for second and later units. The evaluation may receive reduced practice expense depending on its ranking; work and malpractice values are not reduced by this rule.
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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