Summary & Overview
CPT 97162: Physical Therapy Evaluation, Moderate Complexity
CPT code 97162 is a nationally recognized billing code for physical therapy evaluations of moderate complexity. This code is used by physical therapists to document and bill for services that involve a comprehensive assessment of a patient's medical history, physical examination, and clinical decision making. The evaluation typically lasts about 30 minutes and is performed in an office setting.
Major payers covering this code include Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare. Understanding the use and coverage of CPT 97162 is essential for providers, payers, and policy analysts, as it impacts reimbursement, clinical workflow, and patient access to physical therapy services.
This publication provides an overview of the clinical context for CPT 97162, including its description, typical site of service, and its role in the physical therapy service line. Readers will gain insights into payer coverage, relevant policy updates, and benchmarks for this code. The information is designed to support stakeholders in navigating the evolving landscape of physical therapy billing and reimbursement.
CPT Code Overview
CPT 97162 represents a physical therapy evaluation involving history, examination, and clinical decision making of moderate complexity. This service typically requires about 30 minutes of face-to-face interaction with the patient and/or their family. The evaluation is designed to assess the patient's condition, develop a treatment plan, and determine the appropriate level of care. The most common site of service for this procedure is the office setting (POS 11). This code is used by physical therapists to document and bill for moderate complexity evaluations, ensuring accurate representation of the clinical work performed.
Clinical & Coding Specifications
Clinical Context
A patient presents to a physical therapy office (Place of Service 11) with moderate musculoskeletal complaints, such as low back pain or knee pain, and reports difficulty walking or generalized muscle weakness. The physical therapist conducts a moderate complexity evaluation, which includes a detailed history, examination, and clinical decision making. The session typically lasts 30 minutes face-to-face with the patient and/or their family. The evaluation assesses functional limitations, pain, and mobility, and forms the basis for developing a tailored physical therapy plan of care.
Coding Specifications
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Modifiers:
59- Distinct Procedural Service: Used when a procedure or service is distinct or independent from other services performed on the same day.GP- Services delivered under an outpatient physical therapy plan of care: Indicates that the service is part of a physical therapy plan.
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Provider Taxonomies:
Taxonomy Code Specialty Name 225100000XPhysical Therapist 2251P0200XPhysical Therapist in Private Practice 2251X0800XOrthopedic Physical Therapist
These taxonomies represent providers qualified to perform physical therapy evaluations, including those in private practice and with orthopedic specialization.
Related Diagnoses
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M54.5- Low back pain- Relevant for patients presenting with back pain requiring physical therapy evaluation.
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M25.561- Pain in right knee- Indicates right knee pain, commonly assessed in physical therapy evaluations.
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M25.562- Pain in left knee- Indicates left knee pain, also frequently evaluated by physical therapists.
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R26.2- Difficulty in walking, not elsewhere classified- Used for patients with gait disturbances or mobility issues, often addressed in physical therapy.
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M62.81- Muscle weakness (generalized)- Represents generalized muscle weakness, a common reason for physical therapy assessment.
Related CPT Codes
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97161- Physical therapy evaluation: history, examination, and clinical decision making of low complexity. Typically, 20 minutes are spent face-to-face with the patient and/or family.- Used for patients with less complex conditions and fewer impairments. May be selected as an alternative to
97162when clinical presentation is less involved.
- Used for patients with less complex conditions and fewer impairments. May be selected as an alternative to
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97163- Physical therapy evaluation: history, examination, and clinical decision making of high complexity. Typically, 45 minutes are spent face-to-face with the patient and/or family.- Used for patients with more complex conditions, multiple comorbidities, or significant functional limitations. May be selected as an alternative to
97162when clinical presentation is more involved.
- Used for patients with more complex conditions, multiple comorbidities, or significant functional limitations. May be selected as an alternative to
These codes are alternatives to 97162 and are chosen based on the complexity of the patient's condition and the evaluation required. Only one evaluation code is typically billed per patient encounter.
National Reimbursement Benchmarks
Medicare's national mean rate for CPT code 97162 is $101.40, which is slightly higher than the BUCA (average commercial) mean rate of $97.88. Among commercial payers, Cigna and UnitedHealth Group offer the highest mean rates at $115.58 and $110.70, respectively, while Aetna is the lowest at $92.27.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare has the tightest range at $8.00, indicating relatively consistent reimbursement rates. In contrast, Cigna shows the widest dispersion at $67.00, reflecting greater variability in rates. Other commercial payers such as Aetna and Blue Cross Blue Shield have moderate ranges of $44.00 and $35.50, respectively.
The table and chart below present a detailed breakdown of national benchmarks for CPT code 97162 across major payers.
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