CPT Code 97162: Physical Therapy Evaluation – Moderate Complexity

What is moderate complexity physical  therapy evaluation?

CPT code 97162 is used to report a moderate complexity physical therapy evaluation performed by licensed physical therapists. This evaluation applies when a patient’s clinical presentation is moderately complex and cannot be sufficiently addressed by a low complexity evaluation (97161), but does not meet the threshold for a high complexity evaluation (97163).

A moderate complexity evaluation typically involves:

• A medical history with one or more personal factors or comorbidities that may affect treatment
• An examination of body systems related to the patient’s condition—such as the musculoskeletal system, neuromuscular system, and cardiovascular system
• Identification of three or more performance deficits in areas such as balance, mobility, muscle strength, or coordination
• Use of standardized tests or standardized patient assessment instruments to establish functional status and clinical findings
• Moderate clinical decision making that considers variable patient's clinical presentation, patient's personal factors, and expected progression

This evaluation process helps physical therapists develop a personalized physical therapy established plan that includes clear treatment plans, measurable assessments, and anticipated outcomes.

Evaluation complexity and its impact on the billing process

When assigning CPT code 97162, it's essential to understand how evaluation complexity influences both the comprehensive assessment and the overall billing process. Evaluation complexity refers to the level of detail, clinical judgment, and problem-solving required by the physical therapist during the patient assessment.

While therapeutic exercises are commonly part of a treatment plan, they do not factor into determining the evaluation code itself. Instead, it's the depth of assessment—including medical and therapy history, the number of performance deficits, and decision-making requirements—that define whether an evaluation is low, moderate, or high in complexity.

A high complexity history, for example, involves extensive comorbidities or multiple prior interventions and is more aligned with CPT code 97163. In contrast, CPT 97162 is appropriate when the patient’s history is moderately detailed but still significantly impacts care planning.

Thoroughly documenting the comprehensive assessment, including medical history and performance limitations, helps justify the complexity level selected and streamlines the billing process. Clear classification of complexity also reduces the risk of upcoding, underbilling, or payment delays.

CPT code 97162 documentation requirements

Proper documentation is essential to ensure accurate billing and maximize reimbursement. For CPT code 97162, the following elements should be documented in detail:

• Patient’s medical history, including prior injuries and comorbidities
• Body structures and body systems affected by the condition
• At least three activity limitations or participation restrictions
• Use of validated outcome measures and functional tools
• Description of the clinical presentation indicating a moderate level of complexity
• Evidence of moderate clinical decision making and how it influences the services provided
• A customized treatment plan within the physical therapy services framework

Clear and thorough documentation also helps prevent claim denials and ensures proper reimbursement from payers like Medicare and commercial insurance plans.

CPT code 97162 billing guidelines

To ensure proper billing and reduce the risk of denied claims, providers should follow these guidelines:

• CPT code 97162 should only be used for the initial evaluation during a new episode of care, unless there's a significant change requiring a re-evaluation (97164)
• The evaluation must reflect moderate complexity in terms of history, impairments, and decision-making
• Do not use this code in the same visit with other evaluation codes like 97161 or 97163
• Use modifier GP to indicate that the service is part of a physical therapy plan of care
• Maintain compliance with documentation standards from CMS and commercial payers to secure accurate reimbursement

Understanding correct coding practices is vital for sustaining your practice’s revenue and avoiding delays in payment.

Other relevant CPT codes

Here are other CPT codes related to physical and occupational therapy evaluations:

• 97161 – Low complexity physical therapy evaluation
• 97163 – High complexity physical therapy evaluation
• 97164 – Re-evaluation of an established physical therapy plan of care
• 97165–97167 – Occupational therapy evaluations (low, moderate, and high complexity)
• 97168 – Re-evaluation of occupational therapy established plan