PT Evaluation (Moderate Complexity) Cost
Pt eval mod complex 30 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 (moderate 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 97162
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 (Moderate Complexity)?
This is the moderate-complexity initial physical therapy evaluation, used when your situation has real complicating factors: one or more health conditions affecting rehab, an evolving rather than stable presentation, or changed function in daily activities. A typical example is knee rehab in someone with diabetes and prior joint surgery. The PT takes a more extensive history and examines more body systems than in a simple case, usually across a 45 to 75 minute appointment that often ends with the first treatment.
What Affects the Cost
- –As the middle evaluation tier, some commercial payers price it above the low-complexity code, while Medicare pays all three tiers equally.
- –Complicated patients tend to need longer courses of care, so the evaluation tier itself signals a larger total spend ahead.
- –First-day treatment units bill in addition to the evaluation.
- –Comorbidities can mean coordination with physicians or extra documentation, occasionally generating separate visits elsewhere.
- –Clinic ownership matters as always: hospital-affiliated clinics add facility fees to every encounter including this one.
How It Is Billed
CPT 97162 requires documented complicating elements: a history with one or two personal factors or comorbidities relevant to the plan, examination of at least three body systems or regions, and an evolving clinical presentation. The distinction among 97161, 97162, and 97163 is clinical complexity, not appointment length. Same-day treatment bills separately, and mid-course reassessment uses the re-evaluation code rather than repeating an initial evaluation.
Insurance & Coverage Notes
Coverage is identical in structure to any PT evaluation: it consumes a visit under your annual therapy benefit with your standard cost sharing, and referral or authorization requirements depend on your plan, not on the complexity tier. Under Medicare the payment is the same across tiers, so patients see no cost difference; under some commercial fee schedules the moderate tier reimburses somewhat more, which can flow through to coinsurance-based cost sharing. The complexity coding primarily affects clinic documentation and audit exposure.
Questions to Ask Before Booking
- 1.What makes my case moderate complexity, and does that tier change what I pay under my plan?
- 2.Given my other health conditions, how long a course of therapy should I budget for?
- 3.Will you treat me on evaluation day, and what will that first combined visit cost?
- 4.Does my insurer require a referral or pre-authorization before this evaluation?
- 5.How will you coordinate with my physician, and does that generate any separate charges?
PT Evaluation (Moderate Complexity) (CPT 97162): questions
The 2026 national Medicare physician rate for CPT 97162 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 97162 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 moderate-complexity initial physical therapy evaluation, used when your situation has real complicating factors: one or more health conditions affecting rehab, an evolving rather than stable presentation, or changed function in daily activities. A typical example is knee rehab in someone with diabetes and prior joint surgery. The PT takes a more extensive history and examines more body systems than in a simple case, usually across a 45 to 75 minute appointment that often ends with the first treatment. CMS bills it as “Pt eval mod complex 30 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.