Evaluation & management · General
Moderate-complexity physical therapy evaluation requiring documented history with one to two comorbidities or personal factors, examination of three or more body system elements with measurable findings, and moderate clinical decision-making for an evolving presentation — typically 30 minutes face-to-face.
Verified May 8, 2026 · 6 sources ↓
- Medicare
- $97.86
- Total RVUs
- 2.93
- Global, days
- Region
- General
Documentation requirements
What must appear in the operative or office note to support the claim.
Source · Editorial brief grounded in 6 cited references ↓
- Patient history documenting one to two comorbidities or personal/environmental factors that affect care
- Examination of three or more body structure and function elements with measurable, standardized test results
- Clinical decision-making narrative showing moderate complexity appropriate to an evolving or changing presentation
- Modifier GP appended to the claim line for Medicare to indicate service is under a PT plan of care
- Standardized outcome or assessment tools used and results recorded by name in the note
- Face-to-face time with patient and/or family documented when time-based support is needed
Applicable modifiers
Modifiers commonly billed with this code.
Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual
What this code covers
Source · Editorial summary grounded in 6 cited references ↓
97162 is the middle tier of the three-level PT evaluation series (97161–97163). It requires all three complexity pillars to be met: a patient history that captures one or two comorbidities or personal/environmental factors affecting care; a physical examination of three or more body structure and function elements — such as joint mobility, muscle strength, gait, or neuromuscular function — documented with measurable outcomes; and moderate clinical decision-making appropriate for a presentation that is evolving or changing in character. Standardized tests and measures must be used. Miss any pillar and the note supports 97161, not 97162.
For Medicare, modifier GP is required on every 97162 claim line to indicate the service was rendered under a physical therapy plan of care. Without GP, the claim processes incorrectly or rejects outright. The code carries a XXX global period, meaning standard surgical global rules don't apply — therapy-specific coverage rules govern instead.
An NCCI Procedure-to-Procedure edit exists between 97162 and 97140 (manual therapy). Billing both on the same date without a modifier triggers automatic denial of 97140. Modifier 59 (or an appropriate X-modifier) appended to 97140 bypasses the edit — but only when the documentation shows the manual therapy served a distinct clinical purpose separate from the evaluation itself. Audit teams look for notes that use modifier 59 as a reflex rather than a supported clinical distinction.
RVU & reimbursement
Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.
Source · CMS Physician Fee Schedule, RVU26A · January 2026
| Work RVU | 1.54 |
| Practice expense RVU | 1.38 |
| Malpractice RVU | 0.01 |
| Total RVU | 2.93 |
| Medicare national rate | $97.86 |
| Global period | days |
Payment by site of service
Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.
Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026
| Setting | Medicare rate (national) |
|---|---|
Office (PFS non-facility) Procedure performed in physician's office | $97.86 |
Common denial reasons
The recurring reasons claims for CPT 97162 get rejected.
Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓
- Missing modifier GP on Medicare claims — claim processes incorrectly or rejects without it
- Documentation supports only one comorbidity/factor and fewer than three examination elements, downgrading to 97161
- 97140 billed same-day without modifier 59 or X-modifier — NCCI PTP edit auto-denies the 97140 line
- Billing 97162 alongside 97750 (physical performance test) on the same date — CMS treats the assessment as inclusive within the evaluation
- Upcoding flag: note describes a straightforward, stable presentation with no evolving clinical factors, which does not meet moderate complexity criteria
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 6 cited references ↓
01What separates 97162 from 97161 and 97163?
02Is modifier GP always required for Medicare billing of 97162?
03Can you bill 97162 and 97140 on the same date?
04Does 97162 follow the 8-minute rule?
05Can an orthopedic surgeon or PM&R physician bill 97162, or is it PT-only?
06What standardized tests satisfy the 97162 documentation requirement?
Sources & references
Editorial content was developed using the following public sources. Last verified May 8, 2026.
- 01CMS Physician Fee Schedule 2026
- 02cms.govhttps://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56566
- 03cms.govhttps://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57067&ver=26&=
- 04cms.govhttps://www.cms.gov/files/document/2025nccimedicarepolicymanualcompletepdf.pdf
- 05medsolercm.comhttps://medsolercm.com/blog/cpt-code-97162-billing-guide
- 06aapc.comhttps://www.aapc.com/codes/cpt-codes/97162
Mira AI Scribe
Mira's AI scribe captures the specific comorbidities and personal factors noted in the patient history, names each body structure and function element examined with its measured value, records the standardized assessment tool used and score, and documents the therapist's clinical reasoning for why the presentation is evolving or changing. That structured capture prevents the most common audit flag for 97162: a note that describes findings but omits the complexity rationale needed to distinguish this code from 97161.
See how Mira captures CPT 97162 documentation