CPT Code 97162: The Complete Billing, Modifiers & Reimbursement Guide for 2026

CPT code 97162 is the billing code used to report a moderate-complexity physical therapy evaluation, typically involving approximately 30 minutes of face-to-face patient contact, assessment of three or more body systems, and moderate-level clinical decision-making.

That sounds simple enough. But in practice, 97162 is one of the most commonly miscoded evaluation codes in physical therapy billing. Documentation doesn't support the claimed complexity level. The wrong modifier gets appended, or no modifier at all. Then the claim triggers an NCCI edit nobody caught during charge review.

That $101 reimbursement your practice expected to collect? It's sitting as a denial in an aging bucket that nobody's following up on.

This guide covers everything you need to bill CPT code 97162 correctly in 2026:

• What CPT code 97162 means and when to use it
• How 97162 differs from 97161 and 97163
• Documentation requirements that prevent audit failures
• Which modifiers to use and when to apply them
• NCCI bundling rules for codes billed alongside 97162
• 2026 Medicare reimbursement rates and RVU changes
• Top denial reasons and how to prevent them
• Telehealth status for PT evaluations after January 2026

What Is CPT Code 97162?

97162 CPT Code Description

The American Medical Association (AMA) defines CPT code 97162 as a physical therapy evaluation of moderate complexity. It was introduced in January 2017 when the tiered evaluation coding system replaced the older, single-code structure.

Before 2017, therapists billed all evaluations under one code regardless of how complex the case was. The current system uses three tiers. CPT 97162 is the moderate complexity PT eval code, sitting between 97161 (low) and 97163 (high). In most outpatient clinics, it's the one you'll bill most often.

The full 97162 CPT description breaks down into three required pillars:

Here's the critical point most billers miss: the code is determined by the lowest qualifying pillar, not the highest. If your history and exam support moderate complexity 

That's the 97162 CPT code definition in practical terms. All three pillars must support moderate complexity in your documentation. If even one falls into "low complexity" territory, the correct code is 97161. Payers catch this during audits more often than you'd expect.

Is 97162 a Timed or Untimed Code?

CPT code 97162 is an untimed, service-based code. You bill it once per evaluation session regardless of exact time spent, as long as the evaluation meets all moderate-complexity criteria.

The typical benchmark is approximately 30 minutes of face-to-face patient contact. But what matters for billing is complexity, not the clock.

Here's where practices get tripped up: evaluation codes like 97162 don't follow the 8-minute rule. That rule applies only to timed therapeutic procedure codes such as 97110 and 97140. When a therapist performs both an evaluation and treatment on the same day, evaluation time doesn't count toward the 8-minute calculation for treatment units. Separate buckets entirely.

Some practices bill 97162 just because the session lasted 30 minutes. That's not how it works. If your documentation shows a stable patient with minimal comorbidities, 97161 is the correct code regardless of how long the evaluation took.

Who Can Bill CPT Code 97162?

Only qualified clinicians can perform and bill therapy evaluations. Physical therapist assistants and occupational therapy assistants can't perform initial evaluations or re-evaluations. This applies across Medicare, Medicaid, and commercial payers.

The rendering NPI on the claim must match the licensed therapist who personally conducted the evaluation. When a PTA's NPI shows up on a 97162 claim line, the result is a denial. It's a credentialing and enrollment issue that needs to be solved at the scheduling level, not after the claim gets rejected.

When Should You Use CPT Code 97162?

Understanding what the 97162 CPT code means is the easy part. Applying it correctly is where billing errors happen.

Clinical Criteria for Selecting 97162

Choosing the right CPT code for a physical therapy evaluation and treatment comes down to three documented criteria. Use CPT code 97162 only when all three are met:

1. History: 1 to 2 comorbidities or personal factors.
   The patient has at least one condition or circumstance that complicates the plan of care. Diabetes, obesity, prior surgeries, advanced age, or a high-stress lifestyle all count. These don't need to be the primary diagnosis; they just need to influence treatment decisions.
2. Examination: 3 or more elements assessed.
   Your evaluation must cover at least three distinct areas across body structures, functions, activity limitations, or participation restrictions. Strength plus ROM plus balance plus gait gets you there. Only two elements? That's 97161 territory.
3. Clinical presentation: evolving with changing characteristics.
   An evolving clinical presentation means the patient's condition isn't stable or predictable. Pain levels fluctuate. New limitations show up between visits. Weight-bearing tolerance shifts. The condition is actively changing, which forces moderate-level clinical reasoning when building the treatment plan.

If any single pillar falls below moderate complexity, downcode to 97161. When all three point to high complexity, with three or more comorbidities and an unstable presentation, bill 97163 instead.

Real-World Scenarios for CPT 97162

Here's how 97162 CPT code physical therapy billing plays out in actual clinical practice.

Post-surgical knee patient with diabetes.
A 58-year-old recovering from total knee replacement also has Type 2 diabetes, which affects wound healing and exercise tolerance. The PT evaluates ROM, strength, gait, and balance. Pain and mobility change weekly as the patient shifts from acute to sub-acute recovery. Bill 97162.

Chronic low back pain with obesity.
A 45-year-old office worker with persistent lumbar radiculopathy and a BMI of 34 reports pain fluctuating between 4/10 and 8/10. Assessment covers posture, flexibility, core strength, and functional mobility. Two comorbidities, four exam elements, evolving symptoms. Bill 97162.

Older adult referred after a fall.
A 72-year-old with hypertension and arthritis is referred after falling at home. Evaluation includes balance, gait, lower extremity strength, and neuromuscular coordination. Movement patterns are actively changing as recovery progresses. Bill 97162.

In all three cases, documentation must connect the comorbidities to the treatment approach and explain why the presentation is evolving. Without that connection, payers can argue the eval was really low complexity. That's when downcoding and denials start.

CPT 97161 vs 97162 vs 97163: How to Choose the Right Evaluation Code

The PT evaluation CPT code you select tells the payer exactly how complex the patient's case was. Pick the wrong tier and you're either leaving revenue on the table or inviting an audit.

Side-by-Side Comparison Table

Rates vary by locality. Verify using the CMS PFS Look-Up Tool.

The CPT code 97161 description covers the simplest cases: stable condition, minimal testing, straightforward decision-making. A patient with a basic ankle sprain and no comorbidities fits here.

CPT 97163 sits at the other end. Think of a patient with multiple chronic conditions, four or more systems to evaluate, and a clinical picture that changes unpredictably. Stroke rehab patients with cardiac history and cognitive deficits often fall into this category. The 97163 CPT code description reflects that level of complexity.

Between those extremes, the 97162 CPT code is where most outpatient evaluations land. Moderate comorbidities, three or more exam elements, and symptoms that shift between visits.

The real difference between 97161 and 97162 isn't time. It's the complexity your documentation supports. A 35-minute evaluation on a stable patient with one simple complaint is still 97161. What bumps you to 97162 is clinical reasoning, not minutes on the clock.

Common Coding Mistake: Time Doesn't Equal Complexity

We see this constantly. A therapist spends 30 minutes on an eval and assumes that automatically means 97162. But when the note shows a stable patient with no significant comorbidities and only two exam elements, time alone won't justify the code.

Auditors compare documentation against the complexity criteria. Not against a stopwatch. If the note reads like a low-complexity case, it gets treated like one regardless of how long the session lasted.

Code selection must match what's documented. Period.

Not sure if your evaluations are coded at the right complexity level? That uncertainty costs money in both directions. Undercoding leaves revenue uncollected. Overcoding triggers denials and compliance risk. MedSole RCM's coding specialists match documentation to the correct code on every claim, so your practice gets reimbursed accurately.

Documentation Requirements for CPT Code 97162

Good documentation is the single best defense against audits, downcoding, and recoupment. For 97162 CPT code claims, payers look for one thing: does the note support moderate complexity across all three pillars? When it doesn't, expect downcoded evaluations, denied claims, or money clawed back after review.

What Auditors Look For in a 97162 Evaluation Note

Medicare contractors and commercial payers audit CPT code 97162 claims by scanning for specific evidence that supports moderate complexity. Vague notes and template-driven records are the number one reason evaluations get downcoded or denied entirely.

Your documentation needs to cover all of the following:

1. Patient History

• At least one to two named comorbidities or personal factors (example: "Patient has Type 2 diabetes, A1C 7.8, and BMI of 31, both affecting exercise tolerance")
• Prior level of function versus current functional limitations
• Relevant surgical or injury history

1. Examination Findings

• Assessment of three or more distinct elements with objective, measurable data
• ROM documented in degrees, not just "decreased ROM"
• Manual muscle test grades recorded (example: "L quad 3+/5")
• Standardized test scores: Berg Balance Scale, Timed Up and Go, or similar

1. Clinical Decision-Making

• Clear explanation of why the presentation is evolving (example: "Pain fluctuating from 4/10 to 8/10 over the past week with new nighttime discomfort")
• How comorbidities directly influence the treatment approach
• Specific, measurable goals tied to findings (example: "Improve TUG from 18 sec to 12 sec within six weeks")
• Rationale for chosen interventions

1. Medical Necessity

• Why physical therapy is needed and appropriate for this patient
• Direct connection between evaluation findings and functional deficits

Skip any of these elements and payers have an opening to downcode or deny. Once a claim gets kicked back, the follow-up process to overturn it takes far more time and resources than doing the documentation right from the start.

Documentation Format That Protects Your Practice

The APTA recommends either a SOAP note format or an evaluation-specific template. Both work well for 97162 CPT code physical therapy documentation. What matters is that an auditor can find every required element quickly, without having to dig through narrative text.

A good benchmark: if someone reviewing your note can't locate the comorbidities, the three or more exam elements, and the evolving clinical rationale within 60 seconds, the documentation needs improvement.

⚠️ Audit Red Flag: Cloned notes are a fast track to a targeted medical review. When every patient's evaluation reads identically, with only the name and date of service changed, it signals a compliance problem payers won't ignore. Every 97162 note must reflect the individual patient's clinical picture.

One practical step: have your lead therapist review two to three evaluation notes per week against these documentation requirements. A five-minute internal check catches issues that would otherwise become denials 30 days later.

Which Modifiers Should You Use with CPT Code 97162?

Picking the wrong 97162 CPT code modifier, or skipping one entirely, is one of the most preventable reasons PT claims get denied. It happens constantly because modifier rules vary by payer, and the guidance isn't always straightforward.

Essential Modifiers for 97162

The full list of modifiers that apply when billing CPT 97162:

One CPT 97162 modifier to explicitly avoid: GN. That designator is for speech-language pathology services. Billing 97162 with GN instead of GP triggers an immediate denial.

The 97162 Physical Therapy Modifier 59 vs XE Decision

CMS has stated that X-modifiers (XE, XP, XS, XU) should replace Modifier 59 whenever possible because they offer greater specificity. In practice, not every payer has caught up. Plenty of commercial carriers still process Modifier 59 without issue.

Check your payer's preference before submitting. Some reject 59 and require XE; others don't recognize X-modifiers at all. Your team should verify this during benefit verification. Adding modifier preference to that checklist takes seconds and prevents days of rework.

The KX Modifier in 2026

For 2026, the KX threshold sits at $2,480 for combined PT and SLP services under Medicare. Once a patient's cumulative therapy charges cross that dollar amount in a calendar year, every subsequent claim line needs KX appended. That includes evaluations billed under the 97162 CPT code. Without it, the claim auto-denies.

The Targeted Medical Review threshold stays at $3,000. When your patient's charges approach that number, treat every claim like it's heading straight to audit, because it might be.

Modifier errors are among the easiest denial categories to eliminate, and the most expensive to ignore. If your team isn't sure which modifier to use, those gaps show up as preventable denials. MedSole RCM tracks KX thresholds in real time and applies the correct modifier on every PT claim before submission. Already dealing with modifier-related denials? Our denial management team can help.

Can You Bill 97162 with Other CPT Codes? NCCI Bundling Rules Explained

Yes, the 97162 CPT code can be billed alongside treatment codes on the same date of service. But certain combinations trigger National Correct Coding Initiative (NCCI) edits that automatically deny the bundled code unless you apply the right modifier.

This is one of the most common sources of preventable denials in PT billing. The claim looks clean when it leaves your office, then comes back denied 30 days later because nobody caught the edit conflict. Here's what you need to know about the most frequent code pairings.

97162 and 97140: Billed Together

An NCCI Procedure-to-Procedure (PTP) edit exists between CPT 97162 and CPT 97140 (manual therapy). Bill both on the same date without a modifier and CMS denies the 97140 line automatically.

The fix: append Modifier 59 or the appropriate X-modifier (XE, XS, XP, or XU) to CPT 97140. Your documentation must support that the manual therapy was a distinct, separately identifiable service from the evaluation. The APTA's NCCI guidance from January 2020 confirms this requirement.

Don't just slap Modifier 59 on the claim and hope for the best. If an auditor asks why you billed 97162 and 97140 billed together on the same visit, your note needs to show the evaluation and manual therapy addressed different clinical purposes. Otherwise, you're looking at a recoupment.

97162 and 97110: Billed Together

Can 97162 and 97110 be billed together? Generally, yes. These two codes aren't currently paired in the NCCI PTP edit tables, so billing CPT 97162 alongside CPT 97110 (therapeutic exercise) on the same date of service doesn't typically trigger an automatic denial.

One important caveat: CMS updates these edit tables every quarter. The Q1 2026 update was released December 1, 2025. Code pairings that weren't flagged last quarter can show up in the next release. Build a habit of checking the current NCCI file at least quarterly, especially for code combinations your practice bills frequently.

Codes That Cannot Be Billed Separately on Evaluation Day

Here's where practices lose money without realizing it. CMS Medicare guidance, including Noridian's coverage articles, states that formal assessment codes like CPT 97750 (physical performance testing) and certain manual muscle testing codes are considered inclusive within the initial evaluation. They aren't separately reimbursable on the same date as a 97162 evaluation.

Billing these separately on eval day results in a bundling denial. CPT 97162 cannot be billed separately from these assessment components because CMS considers them part of the evaluation itself. If you need to perform formal testing beyond what's included in the eval, schedule it for a different date of service when medically appropriate.

Quick-Reference Bundling Table

NCCI edit tables update quarterly. Verify current pairings before changing billing patterns.

When bundling rules trip up your billing team, the resulting denials don't just sit quietly. They age. And aged claims that miss timely filing deadlines become permanent write-offs. That's a revenue cycle management problem that compounds every month it goes unaddressed.

CPT Code 97162 Reimbursement Rates: Medicare and Commercial Payers [2026]

Knowing what 97162 CPT code reimbursement looks like in 2026 helps you set realistic revenue expectations and spot underpayments before they pile up.

2026 Medicare National Payment Rate

Under the 2026 Medicare Physician Fee Schedule (PFS), the 97162 CPT code Medicare national non-facility payment is approximately $101.20. That number comes from multiplying the code's total Relative Value Units by the 2026 conversion factor.

Here's how the math breaks down:

Verify your locality-adjusted rate using the CMS PFS Look-Up Tool. Payments vary by Geographic Practice Cost Index (GPCI).

The 2026 conversion factor rose to $33.40, up from $32.35 in 2025. That's a 3.26% nominal increase. But CMS also applied a permanent 2.5% efficiency adjustment to work RVUs for untimed codes, and 97162 falls squarely in that category. Net result: most practices see 97162 reimbursement stay flat or dip roughly 1% compared to last year.

If you're wondering why your deposit doesn't reflect the "raise" you heard about, this is why. The conversion factor went up while the RVU value went down. They largely cancel each other out.

Commercial Payer Reimbursement Estimates

Commercial rates for 97162 vary widely. Contract terms, geographic region, and plan type all influence what your practice actually collects. The table below reflects reported industry estimates:

⚠️ Disclaimer: These rates are estimates based on publicly available data and reported industry figures. Actual reimbursement varies by geographic location, contract terms, network status, and specific plan design. Always verify contracted rates with each payer. Medicare rates should be confirmed through the CMS PFS Look-Up Tool.

What stands out in this table is the range. The same CPT code pays $35 from one plan and $220 from another. That kind of variance means your practice's payer mix directly determines whether 97162 evaluations are profitable or barely cover overhead.

If you haven't reviewed your contracted rates against these benchmarks recently, you might be collecting far less than comparable practices in your area. That's revenue you've already earned but aren't receiving.

Most PT practices don't realize how much revenue slips through the cracks until someone looks at the numbers. Undercoded evaluations, missed modifiers, and below-market contracted rates add up fast. When you're ready to find out where your billing stands, MedSole RCM's revenue recovery audits identify exactly what's being left behind, no guesswork involved. See how it works.

What Changed for CPT 97162 in 2026? Key Medicare Updates

Several 2026 Medicare policy changes hit the 97162 CPT code from multiple angles. The conversion factor went up. Work RVUs went down. And the telehealth rules that PT practices relied on have expired.

The 2026 Conversion Factor: Why the "Raise" Doesn't Feel Like One

CMS increased the 2026 conversion factor to $33.4009 for most clinicians, up from $32.35 in 2025. For practices in qualifying Alternative Payment Models, the rate sits slightly higher at $33.5675. On paper, that's a 3.26% bump.

Here's the catch. CMS simultaneously applied a permanent 2.5% efficiency adjustment to work RVUs for nearly all untimed codes. The 97162 CPT code is untimed, so the RVU value driving your payment dropped while the multiplier went up. They largely cancel each other out.

After both adjustments, the 97162 CPT code Medicare payment picture is straightforward: net revenue from evaluations stays essentially flat, possibly down 1% from 2025. Practices that budgeted around a 3% reimbursement increase will feel the gap.

CMS reimbursement for 97162 evaluations won't grow unless RVUs get recalibrated in a future rulemaking cycle. Until then, the only way to protect revenue is making sure every evaluation is coded at the correct complexity, documented fully, and collected without denial delays.

Telehealth Status for PT Evaluations After January 2026

Medicare telehealth flexibilities for physical therapists were extended through January 30, 2026, under H.R. 5371. As of February 2026, those flexibilities have expired unless Congress passed additional legislation after that date.

🚨 Action Required: If your practice bills PT evaluations via telehealth for Medicare patients, confirm current eligibility with your MAC for dates of service after January 30, 2026. 97162 billing via telehealth without confirmed coverage triggers automatic "provider not eligible" denials. Verify prior authorization and coverage requirements with each payer before scheduling telehealth evaluations.

Commercial payers may still cover telehealth PT evaluations, but coverage varies by plan and state. Don't assume what worked last quarter still applies.

NCCI Edits and MUE Updates: Q1 2026

CMS released Q1 2026 NCCI Procedure-to-Procedure edits effective January 1, 2026, posted December 1, 2025. Medically Unlikely Edits were updated in the same release.

Code combinations that paid fine last quarter might now trigger denials. The CPT 97162 frequency limit, set by the MUE, typically restricts this code to one unit per date of service. Verify the current quarter's MUE file through your MAC rather than assuming nothing changed. CMS updates these tables quarterly, and surprises happen.

PTA General Supervision: A Scheduling Advantage

General supervision for Physical Therapist Assistants in private practice under Medicare Part B is now permanent. The supervising PT doesn't need to be in the same room or building while the PTA treats. Phone availability is sufficient.

The practical impact: your PTs can focus more of their daily schedule on initial evaluations billed under the 97162 CPT code, while PTAs carry the treatment caseload. That's a scheduling change that improves revenue per provider hour without adding headcount.

Top 5 Denial Reasons for CPT Code 97162 (And How to Prevent Each One)

Most 97162 billing denials fall into a handful of predictable categories. Once you know the patterns, they're preventable with the right charge review process.

Denial #1: Documentation Doesn't Support Moderate Complexity

What happens: The payer reviews your evaluation note and determines the documentation only supports low complexity. The claim gets downcoded to 97161 or denied outright.

How to prevent it: Every 97162 note must explicitly name one to two comorbidities, document three or more examination elements with measurable findings, and explain why the clinical presentation is evolving. Writing "patient presents with multiple issues" won't cut it. Name the conditions. Report the objective test scores. Describe what's changing and why it affects your treatment approach.

Denial #2: Cloned Notes Across Patients

What happens: An auditor finds identical evaluation language across multiple patient records. Same phrases, same template reasoning, different names and dates. A targeted medical review follows, and recoupment is common.

How to prevent it: Templates save time, but they need patient-specific data in every field. If your ROM values, strength grades, and clinical rationale read the same for a 28-year-old athlete and a 70-year-old with diabetes, the documentation has a credibility problem. This is one of the most visible forms of 97162 CPT code misuse that auditors flag.

Denial #3: Missing KX Modifier Above $2,480

What happens: The patient's annual therapy spend crosses the $2,480 KX threshold for combined PT and SLP in 2026, and nobody appended the KX modifier. The claim auto-denies. No human even reviews it.

How to prevent it: Set an EMR alert that fires when a patient reaches $250 below the threshold. Think of it like a warning light on your dashboard. By the time you spot the denial on an aging report, you've already burned billing hours on rework.

Denial #4: PTA Listed as Rendering Provider

What happens: The rendering NPI on the 97162 CPT code claim belongs to a Physical Therapist Assistant. PTAs can't perform evaluations under any payer's rules. Immediate denial.

How to prevent it: Build this check into your scheduling workflow. Evaluation visits go to licensed PTs or OTs only. Verify the rendering NPI matches the qualified clinician before the claim leaves your office. Catching it during claim review is too late. Catch it at scheduling.

Denial #5: Assessment Codes Billed Separately on Eval Day

What happens: The practice bills 97750 or manual muscle testing codes alongside 97162 on the same date. CMS treats those assessments as inclusive within the evaluation. The add-on codes get denied as bundled.

How to prevent it: Save formal testing codes for a separate visit. If you perform the testing during the eval, it's part of the evaluation service, not a separately billable charge.

These five categories account for the bulk of 97162 claim denials across PT practices. Every single one is preventable with consistent charge review and clean submission workflows.

Same denial categories showing up month after month? That's not bad luck. It's a process gap. MedSole RCM's pre-submission scrubbing catches these issues before claims reach the payer. For denials already sitting on your aging report, our denial management specialists handle the appeals and get them resolved.

Related Physical Therapy CPT Codes

CPT 97162 doesn't exist in isolation. It's part of a broader coding family that covers evaluations, re-evaluations, and the treatment codes your therapists bill alongside them. Knowing how these codes relate to each other helps your billing team avoid mismatches and catch errors before claims go out.

Here's a quick reference for the codes that come up most often in PT billing workflows.
 

Each of these codes interacts with 97162 in real billing scenarios. Some are same-day treatment codes that require attention to NCCI bundling rules. Others are alternative evaluation codes where picking the wrong complexity level costs your practice money. And the OT evaluation codes (97165 to 97168) follow the same tiered structure but apply to a different discipline, which matters in multi-discipline practices where PTs and OTs share scheduling systems.

If your practice bills across both PT and OT, make sure your team understands that each discipline gets its own evaluation code per date of service. A PT eval (97162) and an OT eval (97166) on the same day for the same patient are two separate, billable services, as long as the documentation and provider credentials support both.

Frequently Asked Questions About CPT Code 97162

What is the 97162 CPT code?

CPT code 97162 is a medical billing code maintained by the American Medical Association (AMA) that represents a moderate-complexity physical therapy evaluation. It falls under the Physical Therapy Evaluations code range. Therapists use it when the evaluation involves three or more body system assessments, one to two comorbidities affecting the plan of care, and moderate clinical decision-making for an evolving patient presentation.

What is the difference between 97161 and 97162?

CPT 97161 covers low-complexity evaluations with a stable clinical presentation and one to two examination elements. CPT 97162 is for moderate complexity, requiring three or more examination elements, one to two comorbidities, and an evolving presentation. The distinction is driven by documentation, not by how long the session takes. A 30-minute evaluation with a stable patient and minimal comorbidities is still a 97161.

How often can 97162 be billed?

CPT 97162 is a service-based code billed once per evaluation session. It isn't billed in timed units. A therapist can bill one 97162 per initial evaluation per discipline per date of service. If a patient returns after being discharged from therapy, the visit may warrant a new initial evaluation rather than a re-evaluation (97164), depending on the clinical circumstances and documented medical necessity.

How many units are allowed for 97162?

One unit per date of service per provider. Because 97162 is untimed, the 8-minute rule doesn't apply. The Medically Unlikely Edit (MUE) for this code typically limits it to one unit per encounter. Your billing team should verify the current quarter's MUE through CMS tools, since these tables update quarterly.

Can you bill 97162 and 97140 together?

Yes, but there's an NCCI Procedure-to-Procedure edit between these codes. To bypass it, append Modifier 59 or the appropriate X-modifier (XE, XS, XP, or XU) to the 97140 line. Not to 97162. Without that modifier, CMS will automatically deny the manual therapy code. APTA's NCCI guidance confirms this modifier requirement.

What does evolving clinical presentation mean?

An evolving clinical presentation means the patient's condition has changing characteristics rather than remaining stable. Pain levels fluctuate day to day. New symptoms appear. Weight-bearing tolerance shifts. Vital signs change in response to comorbidities. If the patient's presentation is predictable and unchanged, that points to low complexity (97161). Evolving presentation is one of the three required pillars for billing 97162.

What are the CPT code 97162 billing guidelines?

Billing 97162 requires documentation of all three complexity pillars: one to two comorbidities or personal factors in the patient history, examination of three or more body system elements with measurable findings, and moderate clinical decision-making for an evolving presentation. Medicare requires Modifier GP on the claim line. The code is billed once per evaluation, doesn't follow the 8-minute rule, and shouldn't be billed alongside formal assessment codes like 97750 on the same date since CMS considers those inclusive within the evaluation.

What is a re-evaluation in physical therapy?

A re-evaluation is a thorough reassessment performed when a patient experiences a significant, unexpected change in condition. It's billed under CPT 97164. A re-evaluation is not the same as a progress note, which tracks expected, gradual changes between visits. Re-evaluations require the same level of clinical reasoning as initial evaluations and must be documented as medically necessary. Using 97164 when a standard progress note would suffice is a common coding error that invites audit scrutiny.

What are the three categories of clinical assessment for PT evaluations?

The three categories are: patient history (including personal factors and comorbidities), examination of body systems (tests and measures of structures, functions, activity limitations, and participation restrictions), and clinical decision-making (evaluating the complexity of the patient's presentation and determining the plan of care). The level documented across all three categories determines whether the evaluation is coded as 97161, 97162, or 97163. The lowest qualifying category sets the ceiling for the code.

Does 97162 require a referral or prior authorization?

Medicare doesn't require a physician referral for outpatient physical therapy evaluations. But plenty of commercial payers do require either a referral, a prior authorization, or both before they'll cover PT services. Skipping that verification step before the evaluation creates authorization-related denials that are entirely preventable with a quick eligibility check.

What ICD-10 codes are commonly billed with 97162?

Common pairings include M54.5 (low back pain), M25.511 (pain in right shoulder), S83.511A (sprain of anterior cruciate ligament, right knee), M62.81 (muscle weakness, generalized), R26.89 (other abnormalities of gait and mobility), and G81.90 (hemiplegia, unspecified). The ICD-10 code on the claim must support the medical necessity of the PT evaluation. A mismatch between the diagnosis and the documented findings is another common trigger for claim denials.

Protecting Your Revenue with Accurate 97162 Billing

Everything in this guide comes back to five things that determine whether your 97162 claims pay cleanly or create problems downstream.

Documentation drives the code. All three moderate-complexity pillars, history, examination, and clinical decision-making, must be explicitly supported in the evaluation note. The lowest qualifying pillar sets the code. No exceptions.

Modifiers aren't optional. GP goes on every Medicare PT claim. KX kicks in at $2,480. Modifier 59 or an X-modifier is required when billing 97162 alongside 97140. Missing any of these means an automatic denial.

NCCI edits change quarterly. A code combination that paid last quarter can deny this quarter without warning. Check the current edit tables for your most common pairings at least once every 90 days.

2026 reimbursement is essentially flat. The higher conversion factor ($33.40) got offset by the 2.5% RVU efficiency adjustment. At roughly $101.20 per evaluation nationally, there's no room for revenue leakage from coding errors or missed charges.

Compliance dates matter. The KX threshold is $2,480. The targeted medical review zone starts at $3,000. Medicare telehealth flexibilities for PTs expired January 30, 2026. Each of these creates a denial risk if your billing workflow doesn't account for them.

Getting all of this right on every claim, every day, across every payer, is a lot to manage in-house, especially when your team's primary job is treating patients.

MedSole RCM works with physical therapy and rehabilitation practices to handle this end to end. From code selection and modifier accuracy to payer follow-up and denial resolution, our team manages the full revenue cycle so your billing stays clean and your reimbursements stay on track.

When you're ready to stop chasing denials and start collecting what your practice has earned, let's talk.