CPT Code 97162: Description & Reimbursement Guidelines

Physical therapy evaluations are the starting point of every patient’s treatment plan. The physical assessments conducted during such evaluations decide the entire course of future care, and more importantly, how the therapist will get paid. The physical therapy evaluations are mostly billed based on their complexity levels: low, moderate, and high.

In this guide, we will uncover physical therapy evaluations of moderate complexity. Usually, they are billed by CPT code 97162. Here’s how you can use this code correctly in your billing. 

CPT Code 97162 – Description

CPT code 97162 is defined as:

“Physical therapy evaluation: moderate complexity”

Let’s discuss this in detail. The American Medical Association (AMA) defines CPT code 97162 as a physical therapy evaluation of moderate complexity. However, the actual definition does not cover the essential components required for this code to be valid. To use code 97162 in your billing, the following conditions should be met:

• History: A history of the present problem with 1-2 personal factors and/or comorbidities that impact the plan of care.
• Examination: An examination of body systems using standardized tests and measures, addressing a total of 3 or more elements from body structures and functions, activity limitations, and/or participation restrictions.
• Clinical Presentation: An evolving clinical presentation with changing characteristics.
• Clinical Decision-Making: Moderate complexity clinical decision-making using standardized patient assessment instruments and/or measurable assessment of functional outcome.

Another important point to note is that the evaluation under 97162 usually lasts for 30 minutes. However, that’s not a fixed rule. 97162 is not a time-based code; it does not follow the Medicare 8-minute rule. This code is billed per evaluation. For example, whether an evaluation lasts 20 minutes or 40 minutes, you will still bill one unit of this code per day for reimbursement. 

Scenarios Where CPT Code 97162 is Applicable

The description alone does not give you an idea of when to use this code in real cases. So, let’s discuss a couple of real-world scenarios in which CPT code 97162 can be used:

Post-Surgical Knee Rehabilitation

Suppose a patient had a total knee replacement surgery 6 weeks ago. He comes to the clinic for his scheduled examination. The patient also has type 2 diabetes, which is a comorbidity that can impact both the healing process and the exercise tolerance of the patient. During the session, the therapist examines the range of motion, strength, gait pattern, and functional mobility. 

He assesses that the patient is recovering fast, but has fluctuating pain levels and mobility. Since the session involved a moderate-complexity physician therapy evaluation, the billing department can use CPT code 97162 to bill its evaluation component. 

Chronic Low Back Pain with Complicating Factors

Let’s consider another scenario. A patient has chronic low back pain, so she is referred to a physical therapist. The patient has mild obesity and a sedentary lifestyle (2 personal factors affecting the plan of care). During the evaluation, the therapist assesses spinal mobility, core strength, and activity limitations.

The condition is found to be evolving, with symptoms worsening over the past two months. In this case, the physical therapy evaluation session of moderate complexity can be billed with 1 unit of CPT code 97162. 

Applicable Modifiers for CPT Code 97162

The following are some of the most used modifiers with CPT code 97162:

Modifier	Description	Usage
59	Distinct Procedural Service	Indicates that the procedure is distinct and separate from other services performed on the same day.
GP	Physical Therapy Plan Identification	Indicates services provided as part of an outpatient physical therapy plan of care.
GN	Speech-Language Therapy Designation	Explains that the evaluation was performed as part of an outpatient speech-language pathology plan of care.
GO	Occupational Therapy Designation	Identifies services rendered under an outpatient occupational therapy plan of care.
XU	Unusual Non-Overlapping Service	This modifier indicates that the service does not overlap with the usual components of the primary service.

CPT Code 97162 – Reimbursement Guidelines

Here are some additional guidelines that you should consider when filing claims with CPT code 97162:

Provide Detailed Documentation

Documentation is the most important part of any claim. Without detailed documentation and medical records, you have no way to prove the medical necessity of a service. For 97162 claims, make sure to provide the following:

• The specific personal factors and/or comorbidities (1-2) and how they impact the plan of care.
• Standardized tests and measures that were used during the examination, with measurable results for 3+ elements.
• A clear description of the evolving nature of the clinical presentation.
• The clinical reasoning behind moderate-complexity decision-making.
• Functional outcome measures and patient-specific goals.

Be Wary of Additional Rules

• One evaluation per discipline, per date of service. You cannot bill 97162 alongside 97161 or 97163 on the same day. These codes are mutually exclusive.
• Evaluation time does not count toward timed codes. If you perform both an evaluation and treatment on the same day, the evaluation time is separate. Treatment time follows the 8-minute rule independently.

Confirm the Medicare Reimbursement Rate

The reimbursement amount for CPT code 97162 varies for each Medicare Administrative Contractor (MAC) locality. The national average reimbursement amount for 97162 is $97.86 for both facility and non-facility settings.

You can check the exact reimbursement rate for your MAC locality via the PFS Lookup Tool. 

Final Thoughts

Let’s wrap up this guide. In case you missed anything, here’s a quick recap of the essential points:

• CPT code 97162 is used to bill a physical therapy evaluation of moderate complexity.
• The evaluation session usually lasts 30 minutes. However, you can only bill one unit of 97162 per day regardless of the time spent in the session.
• For proper reimbursement, you must append the appropriate modifiers when necessary.

Even with all the precautions, denials are inevitable. You can only reduce the rate of denials. To get the most out of your claims, it is better to get professional physical therapy billing services from third-party companies like NeuraBill. 

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