CPT (Current Procedural Terminology) codes are five-digit numbers that describe every medical service or procedure. Your doctor, hospital, and insurance company use them to communicate exactly what was done. Every line on your medical bill has a CPT code, and knowing the code lets you look up what Medicare pays for that same service.

Why do providers charge so much more than Medicare pays?

Providers set their own "chargemaster" prices, which are essentially list prices. Medicare pays a fixed rate based on the resources each service actually requires (the RVU system for procedures, or the Clinical Lab Fee Schedule for lab tests). Commercial insurers typically pay 150% to 250% of Medicare rates. Uninsured patients are often billed the full chargemaster price, which can be 2x to 30x what Medicare pays.

Can I use Medicare rates to negotiate my bill?

Yes. Medicare rates are the closest thing to a "fair price" benchmark in U.S. healthcare. When negotiating, ask the provider what they accept from Medicare for the same CPT code. Most providers will accept 150% to 200% of Medicare for cash-pay patients, which is still far less than their chargemaster price. Many hospital financial assistance policies also use a multiple of Medicare as their discount floor.

How are Medicare rates calculated?

For most procedures, Medicare uses the Resource-Based Relative Value Scale (RBRVS). Each CPT code gets three RVU components: Work (physician time and skill), Practice Expense (overhead), and Malpractice. These are multiplied by geographic adjustment factors (GPCIs) and a conversion factor ($33.4009 in 2026). Lab tests (80000-89999 range) use a separate Clinical Laboratory Fee Schedule with flat national rates.

CPT 97162

Physical Therapy Evaluation, Moderate Complexity (30 min)

CPT 97162 is a moderate complexity PT evaluation for patients with multiple body areas involved, complicating factors, or evolving conditions. Here is the surprising part: Medicare pays the exact same rate as a low complexity evaluation (97161). Both pay $97.86. Yet average provider charges differ ($179 for 97162 vs $185 for 97161). The complexity designation matters more for documentation and justifying additional treatment than for changing the evaluation price itself. Understanding this distinction helps you evaluate whether the coded complexity matches your actual clinical situation.

Updated May 2026Source: CMS Physician Fee Schedule

CPT 97162 at a Glance

Average provider charge: $179.29
Medicare physician fee (office): $97.86
Medicare physician fee (hospital): varies + separate facility fee
Typical markup: 1.8x over Medicare office rate

Evaluation type: Moderate complexity, 1-2 body regions
When billed: First PT visit (establishes plan of care)
Duration: Approximately 30 minutes
Beneficiaries (2023): 1.3 million

How the Medicare Rate Is Calculated

Medicare does not set prices arbitrarily. Every procedure is valued using Relative Value Units (RVUs) across three components, then multiplied by a national conversion factor of $33.4009 (2026). Here is the exact math for a 97162 evaluation. Notice the RVUs are identical to 97161:

Component	What It Covers	Office (Non-Facility)	Hospital (Facility)
Work RVU	Therapist time, skill, and clinical judgment	1.20	1.20
Practice Expense RVU	Rent, staff, equipment, supplies	1.52	0.32
Malpractice RVU	Professional liability insurance	0.07	0.07
Total RVU		2.79	1.59
x $33.4009	2026 conversion factor	$97.86	$53.11

Same Medicare rate, different implications: Medicare pays $97.86 for both 97161 and 97162. The complexity level does not change the evaluation payment. However, a moderate complexity evaluation documents more involved clinical findings, which can justify more treatment units per session and more total visits in your plan of care. This is where the real cost difference emerges, not in the evaluation itself, but in the downstream treatment it authorizes.

Medicare Rate by State

Medicare adjusts the national rate based on your location using Geographic Practice Cost Indices (GPCIs). The same 97162 evaluation pays differently in each state, ranging from about $72 in Arkansas to $96 in Alaska (a 33% spread). These rates are identical to 97161 state rates because the underlying RVUs are the same.

Medicare Rate by State (2026)

Medicare adjusts payments by location using Geographic Practice Cost Indices (GPCIs). Select your state to see the adjusted rate.

Sample State Rates (Office Setting)

State	Medicare Pays	Avg. Charge	Markup
Texas (Austin)	$80.93	$179.29	2.2x
California (Los Angeles)	$85.66	$179.29	2.1x
New York (Manhattan)	$87.21	$179.29	2.1x
Florida (Fort Lauderdale)	$81.12	$179.29	2.2x
Ohio	$75.39	$179.29	2.4x
Mississippi	$72.41	$179.29	2.5x
Arkansas	$71.82	$179.29	2.5x
Alaska	$95.81	$179.29	1.9x

Rates shown are for the non-facility (office) setting using 2026 GPCIs and the $33.4009 conversion factor. The average provider charge of $179.29 is the 2023 national average from CMS utilization data. Actual charges vary by provider.

What Insured Patients Actually Pay for a 97162 PT Evaluation

If you have health insurance, you do not pay the provider's full charge of $179.29. Your insurer has a negotiated rate with the provider, typically 120% to 180% of the Medicare rate. For a 97162 evaluation, that negotiated rate is usually $120 to $175. What you owe depends on your plan design:

Your Situation	What You Likely Pay	How It Works
Copay plan (deductible met or N/A)	$30 to $75	Flat copay per PT visit (eval counts as one visit)
Coinsurance plan (deductible met)	$24 to $35	20% of the negotiated rate ($120 to $175)
High-deductible plan (deductible NOT met)	$120 to $175	You pay the full negotiated rate until your deductible is met
Medicare Part B	$19.57	20% of the Medicare-approved amount ($97.86)
Medicaid	$0 to $5	Minimal or no cost-sharing in most states

The complexity level affects your treatment plan, not just this visit. A moderate complexity evaluation documents more involved findings, which justifies more treatment units per session and potentially more total visits. If your PT documents moderate complexity, expect a treatment plan with more sessions (12 to 20 visits) compared to low complexity (8 to 12 visits). This has a bigger cost impact than the evaluation itself.

Should You Use Insurance or Pay Cash?

If you have a high-deductible health plan and have not met your deductible, you are paying the full negotiated rate for your PT evaluation. This is typically $120 to $175 for the eval alone, plus $80 to $150 for same-day treatment codes. Many PT clinics offer a cash-pay rate of $100 to $150 for a full first visit (evaluation plus treatment).

When Cash-Pay Wins

You are unlikely to meet your deductible this year
The PT clinic offers an all-inclusive cash rate per session
Your insurance has a high PT copay ($50 to $75 per visit)
You only need a few sessions (less than 6)

When Using Insurance Wins

You are close to meeting your annual deductible
You need extended treatment (12 to 20 sessions)
Your copay is low ($20 to $30 per visit)
You need documentation for a workers comp, auto, or disability claim

Important for moderate complexity cases: A 97162 evaluation typically indicates a more involved condition that requires more treatment sessions. If your PT recommends 15 to 20 visits, the total cost of care (not just the evaluation) is the key number. At $150 per session cash rate across 15 visits, that is $2,250 total. Through insurance with a $40 copay, the same 15 visits cost $600. Run the full math before deciding.

Common Billing Problems with 97162

Coded as moderate when the condition is straightforward

97162 requires documented complicating factors: multiple body regions involved, comorbidities affecting recovery, or an evolving/changing clinical presentation. If your condition is a simple isolated knee strain or a single joint issue with no complicating factors, the evaluation should be coded as 97161 (low complexity). While Medicare pays the same for both, your private insurer may pay differently, and the complexity level can justify more treatment visits than your condition requires.

First visit stacking (eval + multiple treatment codes)

Like 97161, your first visit with a 97162 evaluation will include additional treatment charges. Because moderate complexity suggests a more involved condition, PTs may bill more treatment units on day one (3 to 5 units instead of 2 to 3). This can push first-visit totals to $400 to $600. Ask before your appointment: "What is the expected total charge for my first visit, including evaluation and any treatment?" A clear answer upfront prevents billing surprises.

Re-evaluation charges (97164) during your course of care

Some PT clinics bill a re-evaluation (CPT 97164, approximately $75 to $100) every 10 to 12 visits or when modifying your treatment plan. While periodic reassessment is clinically appropriate, billing a formal re-evaluation code for routine progress checks may not always be justified. If you see 97164 on your bill mid-treatment, ask whether a formal re-evaluation was performed or whether it was simply a progress note during a regular treatment session.

Hospital-based PT facility fees on every visit

If your physical therapy clinic is owned by or affiliated with a hospital system, you may be charged a facility fee on top of the therapy charges for every single visit. For moderate complexity cases requiring 15 to 20 visits, hospital facility fees ($50 to $200 per visit) can add $1,000 to $4,000 to your total cost. An independent outpatient PT clinic typically does not charge facility fees and is significantly cheaper for extended treatment courses.

Related Physical Therapy Codes

Code	Description	Medicare (Office)	Avg. Charge
97161	PT evaluation, low complexity	$97.86	$184.67
97162	PT evaluation, moderate complexity	$97.86	$179.29
97163	PT evaluation, high complexity	$97.86	$195.00
97164	PT re-evaluation	$63.29	$100.00
97110	Therapeutic exercises (per 15 min)	$33.44	$62.00
97140	Manual therapy (per 15 min)	$31.70	$60.00

Frequently Asked Questions

How much does CPT 97162 cost without insurance?

Without insurance, a moderate complexity PT evaluation billed under CPT 97162 costs $120 to $275 depending on the provider and location. The national average charge is $179.29. Many PT clinics offer cash-pay rates of $100 to $150 for the initial evaluation. For comparison, Medicare pays $97.86 for this evaluation in an office setting. Treatment charges on day one add $80 to $200 on top.

Why does 97162 have the same Medicare rate as 97161?

Medicare assigns identical RVU values to 97161 and 97162 (Work RVU 1.20, Practice Expense RVU 1.52, Malpractice RVU 0.07), resulting in the same payment of $97.86. The complexity distinction affects documentation requirements and clinical justification, but CMS does not pay more for moderate versus low complexity PT evaluations. However, private insurers may pay different rates for these codes.

When should a PT evaluation be coded as 97162 instead of 97161?

A PT evaluation should be coded as 97162 (moderate complexity) when the patient presents with problems in 1 to 2 body regions, has complicating factors like comorbidities or prior surgeries, requires moderate clinical decision making, and the evaluation involves an evolving or changing clinical presentation. A single joint issue with no complications would typically be 97161 (low complexity).

Can my PT bill treatment codes on the same day as the evaluation?

Yes. It is standard practice for physical therapists to bill both the evaluation code (97162) and treatment codes (such as 97110, 97140, or 97530) on the same day. Your first PT visit often generates $300 to $500 in total charges because the evaluation ($179 average) is combined with 2 to 4 units of treatment. Ask your PT upfront what the total expected charge will be for your first visit.

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