Physical therapy evaluation CPT codes
2026-09-04 · 9 min read
Three evaluation tiers and a re-evaluation. The tier is decided by four documented elements, not by how long the visit took — and a chart where every evaluation is the middle tier is a chart that has stopped deciding.
The three tiers
| Code | Complexity | The picture it describes |
|---|---|---|
| 97161 | Low | Stable presentation, one or two body-structure elements, no personal factors complicating the plan |
| 97162 | Moderate | Evolving presentation, three or more elements, moderate clinical decision making |
| 97163 | High | Unstable or unpredictable, four or more elements, comorbidities that change the plan |
The codes pay differently, which is why the tier attracts attention. They are not, however, a judgement about how hard you worked; they describe how complicated the patient was.
The four elements
History with or without personal factors and comorbidities. Examination of body systems and the number of elements measured. The clinical presentation — stable, evolving, or unstable. And clinical decision making. Every tier is a combination of those four, and the record has to show each of them in the words of the evaluation, not in a code box.
The presentation element does most of the work
“Stable”, “evolving” and “unstable” are the words that separate the tiers most cleanly. Use them explicitly in the assessment and the tier becomes readable rather than inferred.
97164 re-evaluation
97164 is a formal re-examination triggered by something clinical: new findings, a failure to progress, a change that alters the plan of care. It is not the ten-visit progress note, and billing it on a calendar rather than on a finding is the commonest misuse.
The test is whether the plan changed as a result. If the frequency, the goals or the interventions moved, you re-evaluated. If the note simply summarises where things stand, that is a progress note and it is not separately billable.
The pattern problem
Every evaluation coded 97162 for two years is a pattern, and patterns get sampled. So does the opposite — a practice where every evaluation is high complexity. Neither is inherently fraud and both invite the question, which then costs a week of pulling charts.
A distribution that never varies is a template, not a set of judgements.
A worked case
A 54-year-old with four weeks of unilateral low back pain, no radicular signs, well-controlled hypertension, working full time. History has one comorbidity that does not change the plan. Examination measures lumbar range, a lower-limb neurological screen and two provocation tests — three elements. The presentation is evolving; it has changed twice since onset. Decision making is moderate. That is 97162, and the assessment should say “evolving” in so many words.
Change one fact — the same patient with poorly controlled diabetes, a previous failed episode of care and a night-pain pattern that has not settled — and the presentation is unstable, the comorbidity now changes the plan, and the tier moves. Write down which fact moved it.
The plan that follows the evaluation is a separate document with its own requirements; the plan of care builder covers frequency, duration and goals.
Red flag — refer out
An unstable presentation is a coding tier. Progressive neurological deficit, unexplained weight loss, night pain with a cancer history or bladder change is a referral, whatever tier the evaluation would have been.
CPT is a trademark of the American Medical Association; the descriptions here are our own summaries, not the AMA descriptors. Payer interpretation varies by contract.
Sources
- American Medical Association — Current Procedural Terminology (CPT) — CPT is an AMA trademark; the official descriptors are the AMA's and are paraphrased here, never reproduced · read 2026-09-04
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Published 2026-09-04 · reviewed 2026-09-04