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- Key Takeaways
- The PT evaluation codes are a complexity ladder: 97161 (low), 97162 (moderate), and 97163 (high) for an initial evaluation, and 97164 for a re-evaluation, all untimed at one unit.
- Medicare pays all three initial tiers the same amount, so billing a higher tier than documented adds audit exposure without adding revenue.
- The tier is set by four factors together, history, examination, clinical presentation, and decision-making, and the weakest element caps the complexity, not the exam alone.
- 97164 is a re-evaluation for a documented change in the plan of care, not a routine progress note, and an initial evaluation is billed once per episode, not repeated.
- The evaluation codes are untimed, so the 8-minute rule does not apply, and each requires a standardized assessment or functional outcome measure.
In 2017, CMS replaced the single flat physical therapy evaluation code with three tiered ones, 97161, 97162, and 97163, built to capture low, moderate, and high complexity, plus a re-evaluation code, 97164. Then it did something that still shapes how these codes should be billed: it assigned all three initial tiers the same payment. A high-complexity evaluation that takes 45 minutes and far more documentation pays exactly what a 20-minute low-complexity one does. That means the tier you choose is not about revenue, it is about accuracy and audit exposure, and billing a higher tier than the note supports is risk with no reward. This guide covers all four evaluation codes, how the complexity factors decide the tier, when to use the re-evaluation, and the documentation that keeps the choice defensible.
Current as of 2026. Always verify code status and payment with your specific payer, since policies change.
The four evaluation codes at a glance
Code | Service | Complexity | Billing |
97161 | PT initial evaluation | Low | Untimed, one per evaluation |
97162 | PT initial evaluation | Moderate | Untimed, one per evaluation |
97163 | PT initial evaluation | High | Untimed, one per evaluation |
97164 | PT re-evaluation | Not tiered | Untimed, one per evaluation |
These are untimed codes: one unit per evaluation, no matter how long it takes. The 8-minute rule that governs timed treatment codes does not apply to them.
Standard elements in a PT evaluation
Across the evaluation codes, “elements” refers to the specific components a therapist assesses, which the American Physical Therapy Association groups into:
- Body structures and functions (strength, range of motion, pain, neurological signs)
- Activity limitations (difficulty with tasks like walking, lifting, or stair climbing)
- Participation restrictions (limits on work, home, or community roles)
The number of these elements examined, together with the history, the clinical presentation, and the clinical decision-making, is what separates low, moderate, and high complexity.
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The three levels of complexity
There are three initial evaluation codes, tiered by the complexity of the patient’s condition: 97161 (low), 97162 (moderate), and 97163 (high). Each is defined by five characteristics, duration, history, examination, clinical presentation, and clinical decision-making, shown below. The re-evaluation, 97164, is not tiered.
97161: Low complexity PT evaluation
Characteristic | Requirement |
Duration | Typically 20 minutes face-to-face with the patient and/or family |
History | History of the present problem with no personal factors or comorbidities affecting the plan of care |
Examination | Standardized tests and measures addressing 1 to 2 elements from body structures and functions, activity limitations, and/or participation restrictions |
Clinical presentation | Stable and/or uncomplicated |
Clinical decision-making | Low complexity, using a standardized assessment instrument and/or functional outcome measure |
97162: Moderate complexity PT evaluation
Characteristic | Requirement |
Duration | Typically 30 minutes face-to-face with the patient and/or family |
History | History with 1 to 2 personal factors or comorbidities affecting the plan of care |
Examination | Standardized tests and measures addressing 3 or more elements from body structures and functions, activity limitations, and/or participation restrictions |
Clinical presentation | Evolving, with changing characteristics |
Clinical decision-making | Moderate complexity, using a standardized assessment instrument and/or functional outcome measure |
97163: High complexity PT evaluation
Characteristic | Requirement |
Duration | Typically 45 minutes face-to-face with the patient and/or family |
History | History with 3 or more personal factors or comorbidities affecting the plan of care |
Examination | Standardized tests and measures addressing 4 or more elements from body structures and functions, activity limitations, and/or participation restrictions |
Clinical presentation | Unstable and/or unpredictable |
Clinical decision-making | High complexity, using a standardized assessment instrument and/or functional outcome measure |
97164: PT re-evaluation
Characteristic | Requirement |
When to use | An established plan of care needs revision due to a change in status, a new finding, or failure to progress |
History | Review of history and use of standardized tests and measures |
Examination | An assessment of the changed status, with standardized tests and measures |
Clinical decision-making | A revised plan of care |
Note | Not tiered by complexity, and not a routine progress note |
All four remain untimed, one unit per evaluation. The typical durations above are descriptive of the AMA code definitions, not billing thresholds, since the codes are untimed.
The rule that most often fixes the tier: the weakest element wins
Here is the point competitors skim, and it is where most tier errors come from. The factors are not averaged, and the exam is not the deciding one. The tier is driven by the lowest-level element among them, and clinical decision-making is the element payers scrutinize most.
So a patient with a detailed history and an exam of four elements, which look like high complexity, is still a 97162 if the clinical decision-making only reaches moderate, or a 97161 if it only reaches low. You cannot reach 97163 on a thorough exam alone; the decision-making and the clinical presentation have to support it too. Code to the element that actually caps the complexity, and document that element clearly.
97164: the re-evaluation, and what it is not
97164 is the re-evaluation of an established plan of care, and it replaced the old 97002 in 2017. Unlike the initial codes, it is not tiered, so there is one code regardless of complexity. It is billed when something has changed: a new clinical finding, a significant change in the patient’s status, or a failure to respond that requires revising the plan of care.
The most common 97164 error is billing it as a routine progress note or a scheduled recheck. A re-evaluation requires a professional re-assessment with updated standardized tests and measures and a revised plan of care, documented. A regular progress report, which Medicare already requires periodically and which is included in the treatment, is not separately billable as 97164. An initial evaluation is billed once at the start of an episode of care, not repeated, and a re-evaluation is not billed at every visit. Many payers also limit how often 97164 is covered, so a documented change in status, not the calendar, is what justifies it.
Documentation payers expect
A defensible evaluation claim documents the specific factor that sets the tier, not just the conclusion:
- The history and the personal factors or comorbidities that affect the plan of care, counted
- The examination elements performed, across body structures and functions, activity limitations, and participation restrictions
- The standardized assessment instrument or functional outcome measure used
- The clinical presentation (stable, evolving, or unstable) and the clinical decision-making level, in the therapist’s own reasoning
- A plan of care with measurable goals
- For 97164, what changed and the revised plan
Because the three initial tiers pay the same, the documentation’s job is not to justify payment but to survive an audit: the note has to support the tier billed, especially when it is 97163.
Modifiers for the evaluation codes
- GP: the discipline modifier, required on Medicare claims to show the service was furnished under a physical therapy plan of care (GO for occupational therapy, GN for speech).
- 59 or XP: when an evaluation is billed the same day as a treatment code that hits an NCCI edit, with documentation that the services were distinct.
- KX: when the patient exceeds the annual therapy threshold and continued care is medically necessary, though this applies more to the treatment codes than the evaluation.
- CQ or CO: when a physical or occupational therapist assistant furnishes part of the service.
Common denials and how to avoid them
- Over-tiering. Billing 97163 when the decision-making or presentation only supports a lower tier adds audit risk with no added payment.
- Coding by the exam alone. The weakest element, usually clinical decision-making, caps the tier.
- Billing 97164 as a progress note. The re-evaluation requires a documented change and a revised plan of care.
- Missing the GP modifier. Medicare therapy claims reject without the discipline modifier.
- No standardized measure. The evaluation codes require a standardized assessment or functional outcome.
Related codes
The evaluation codes open the episode; the timed treatment codes carry it. Those include therapeutic exercise (97110), therapeutic activities (97530), manual therapy (97140), neuromuscular re-education (97112), and gait training (97116), each billed in 15-minute units under the 8-minute rule. Our guides to CPT code 97110 and CPT code 97530 cover the unit mechanics the evaluations do not use, and our physical therapy billing guide covers the wider workflow. The occupational therapy evaluation codes mirror this structure: 97165 (low), 97166 (moderate), and 97167 (high) for the initial evaluation, and 97168 for the OT re-evaluation.
Reimbursement
Under the Medicare Physician Fee Schedule, the three initial evaluation tiers (97161, 97162, 97163) carry the same work RVUs and pay the same national amount, roughly in the high nineties before locality adjustments, while the re-evaluation (97164) pays less. The identical payment across tiers is the defining economic fact of these codes. Treat any single figure as illustrative and confirm current rates through the CMS Physician Fee Schedule Look-Up Tool, which updates annually.
The bottom line
The PT evaluation codes reward accuracy, not effort. Because Medicare pays all three initial tiers the same, the goal is to code the tier the documentation actually supports, driven by the weakest element and the clinical decision-making, and to reserve 97164 for a genuine change in the plan of care, not a routine note. For practices that would rather not defend evaluation tiers visit by visit, Neolytix has supported healthcare organizations across the United States for over 14 years, with rehab therapy coding review built into its medical billing services so evaluation claims hold up before they go out.
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This guide reflects Neolytix’s expertise in healthcare revenue cycle management and is intended for educational purposes only. It does not constitute legal or compliance advice. CPT codes and reimbursement rates are periodically updated by the AMA and CMS.
Sources
- Centers for Medicare & Medicaid Services. MLN Matters MM9782, new CPT codes for physical and occupational therapy evaluations (97161 to 97168). https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles
- American Physical Therapy Association. Physical therapy evaluation codes and complexity elements. https://www.apta.org/your-practice/payment/coding-billing
- American Medical Association. CPT physical therapy evaluation codes (97161 to 97164). https://www.ama-assn.org/practice-management/cpt
- Centers for Medicare & Medicaid Services. Physician Fee Schedule Look-Up Tool. https://www.cms.gov/medicare/physician-fee-schedule/search
- AAPC. CPT codes 97161, 97162, 97163, and 97164 reference. https://www.aapc.com/codes/cpt-codes/97161
Frequently Asked Questions
What is the difference between 97161, 97162, and 97163?
All three are initial physical therapy evaluations, separated by complexity. 97161 is low (stable presentation, no comorbidities, 1 to 2 exam elements, low decision-making), 97162 is moderate (evolving presentation, 1 to 2 comorbidities, 3 or more elements), and 97163 is high (unstable presentation, 3 or more comorbidities, 4 or more elements, high decision-making). All three pay the same under Medicare.
Do 97161, 97162, and 97163 pay the same?
Yes, under Medicare. The three initial evaluation tiers carry the same work RVUs and reimburse the same national amount, regardless of complexity or time spent. That is why billing a higher tier than the documentation supports adds audit exposure without adding revenue. The correct approach is to code the tier the note actually supports.
How do I choose the PT evaluation complexity level?
The tier is set by four factors together: history and personal factors, examination elements, clinical presentation, and clinical decision-making. The lowest-level factor caps the tier, and clinical decision-making is scrutinized most. A thorough exam alone does not reach high complexity; the decision-making and presentation must support it too.
What is CPT code 97164 used for?
97164 is the physical therapy re-evaluation, billed when an established plan of care needs revision because of a change in the patient’s status, a new finding, or a failure to progress. It replaced 97002 in 2017 and is not tiered. It is not a routine progress note, which is included in treatment and not separately billable.
Are PT evaluation codes timed?
No. 97161, 97162, 97163, and 97164 are untimed codes, billed once per evaluation regardless of how long the session takes. The 8-minute rule, which governs timed treatment codes like therapeutic exercise, does not apply. The typical times in the descriptors (about 20, 30, and 45 minutes) are descriptive, not billing thresholds.
