PT Evaluation (Low Complexity) Cost
Pt eval low complex 20 min
$97.86Medicare physician fee2026 national office rate- ✓Your ZIP's wage-adjusted hospital and surgery centre rates
- ✓Five nearby hospitals by name, with CMS star ratings
- ✓The add-on codes that typically land on the bill
- ✓A word-for-word script for asking for a good-faith estimate
- ✓A private link you can reopen and share
- ✓Everything in the Premium report
- ✓15 nearby hospitals instead of five
- ✓Filled good-faith-estimate request letter
- ✓Bill-negotiation letter
- ✓Printable PDF download
National Medicare physician rate (2026)
Get the rate for your ZIP
CMS adjusts this CPT by locality. A five-digit ZIP is enough — no account, no insurance card.
What pt evaluation (low complexity) costs at hospitals near you
Everything above is a national average. The hospital you pick in your area moves the bill more than anything else you control.
Rates for your ZIP, 5 named hospitals with CMS ratings, the add-on codes, and the scheduler script.
One-off payment, no account and no subscription. You get a private link and an email. No medical records and no insurance card, ever.
What these numbers are
Every figure on this page is a 2026 Medicare allowed amount: the physician line comes from the Physician Fee Schedule adjusted by geographic practice-cost indices, and the facility totals come from the CMS hospital outpatient (OPPS) and ambulatory surgery centre rates. None of them is a hospital chargemaster price, your insurer's contracted rate, or a quote. Anesthesia, pathology, imaging reads and follow-up care are billed under their own codes when they apply, and an inpatient stay is paid a different way again.
How CMS prices CPT 97161
Work is about 53% of the office total RVU; practice expense is about 47%. Localities with a high PE GPCI move this code more when practice expense is a large share.
Office vs hospital for this code
Office (non-facility) physician rate: $97.86. Hospital (facility) physician rate: $97.86.
Medicare patients typically owe 20% of the allowed amount after the Part B deductible — about $20 for the office physician fee, before any Medigap coverage. That coinsurance does not include a hospital facility fee.
Labeled private-plan and cash ranges on this page are arithmetic multiples of Medicare, not negotiated quotes. Ask the billing office for the CPT code, the site of service, and a good-faith estimate.
What Is PT Evaluation (Low Complexity)?
This is the initial physical therapy evaluation for straightforward cases: a low-complexity assessment where the PT reviews your history, examines movement, strength, and function, and builds your treatment plan. It applies when you have no significant complicating factors, for example a recent simple ankle sprain in an otherwise healthy person. The appointment usually runs 30 to 60 minutes and often includes the first treatment, which is billed separately on top.
What Affects the Cost
- –The evaluation is a one-time charge at the start of care, usually priced above a standard treatment visit.
- –Treatment codes billed at the same first visit stack on top of the evaluation fee.
- –Complexity tiering matters: this low-complexity code is the least expensive of the three PT evaluation levels under many commercial fee schedules, though Medicare currently pays all three tiers the same.
- –Direct access rules let you start PT without a physician referral in most states, saving a doctor visit, but some insurers still require a referral for payment.
- –Hospital outpatient therapy departments attach facility fees to the evaluation that private clinics do not.
How It Is Billed
CPT 97161 is chosen when your history has no personal factors or comorbidities affecting the plan, the exam covers limited body systems, and your presentation is stable; those specific elements, not time, select the code among the three evaluation tiers. Treatment performed the same day bills separately under timed codes. A re-evaluation code (97164) exists for formal reassessment mid-course, which should not be billed at every visit.
Insurance & Coverage Notes
The evaluation counts as one of your plan's allowed therapy visits and is covered the same way, subject to copay or coinsurance. Verify whether your plan requires a physician referral or authorization before the evaluation even in direct-access states, because state law permitting PT access does not obligate your insurer to pay without a referral. Medicare pays the three evaluation complexity levels identically, so the tier chosen affects documentation, not your Medicare cost.
Questions to Ask Before Booking
- 1.Do I need a physician referral for my insurance to pay, even though my state allows direct access?
- 2.What does the evaluation cost, and will treatment on the same day be billed on top?
- 3.Does the evaluation count against my plan's annual visit limit?
- 4.After evaluating me, how many visits and units per visit do you anticipate?
- 5.Is your clinic hospital-owned, and is there a facility fee on this evaluation?
PT Evaluation (Low Complexity) (CPT 97161): questions
The 2026 national Medicare physician rate for CPT 97161 is $97.86 in an office and $97.86 in a hospital. Enter a ZIP code to apply the geographic adjustment for your locality.
For CPT 97161 the office and hospital physician rates are essentially the same ($97.86). The hospital will still usually add a separate facility fee that this page does not show.
This is the initial physical therapy evaluation for straightforward cases: a low-complexity assessment where the PT reviews your history, examines movement, strength, and function, and builds your treatment plan. It applies when you have no significant complicating factors, for example a recent simple ankle sprain in an otherwise healthy person. The appointment usually runs 30 to 60 minutes and often includes the first treatment, which is billed separately on top. CMS bills it as “Pt eval low complex 20 min.”
No. $97.86 is the physician allowed amount. Anesthesia, facility fees, implants, imaging interpretation billed under a different code, and pathology are separate when they apply. Private-plan allowed amounts are often higher than Medicare; your deductible and coinsurance still apply.
For cash-pay surgery shopping, use this CPT as the Medicare floor when you compare written quotes. How cash-price shopping works.