CPT Code for Physical Therapy Evaluation and Treatment Guide

By Awais Afzal, Healthcare Operations & Data Analyst · Published April 5, 2026 · Updated October 14, 2026

The CPT code for physical therapy evaluation and treatment starts with one of three evaluation codes: 97161 (low), 97162 (moderate) or 97163 (high complexity), chosen from history, examination, clinical presentation and decision making. Daily treatment is then billed with timed codes such as 97110 and 97530, counted in 15-minute units.

Most denials in therapy billing start with a mismatch between the note and the code: an evaluation level the record does not support, or timed units that the minutes cannot back up. This guide covers both halves of a new-patient visit, the evaluation and the treatment that follows, and the modifiers and documentation that connect them. It is written for clinic owners, billing staff and therapists who need to decide how to code, not just what the codes are.

Everything below describes Medicare rules unless it says otherwise. Commercial payers often follow similar logic but can differ, so contract terms always come first. Descriptions are our own summaries; the AMA owns the official CPT wording.

How a physical therapy visit is coded

A new-patient therapy visit usually produces two kinds of lines on a claim. The first is one evaluation code. The second is one or more treatment codes, each describing a service delivered during the visit. A diagnosis code on the claim explains why the care was needed, and the plan of care must list the patient’s diagnoses, so the diagnosis, the plan and the procedure codes should all tell the same story.

Since January 2017, physical therapists have used three evaluation codes and one re-evaluation code, according to APTA. Those are 97161, 97162, 97163 and 97164. Everything else on the claim, including exercise, manual work and functional training, is a treatment code.

Two practical points shape every decision that follows. First, the evaluation level depends on what the therapist documents, so the code is chosen from the note rather than from the patient’s story alone. Second, treatment units depend on minutes, so the note has to show them. If you want the broader picture of how procedure, diagnosis and HCPCS codes fit together, our guide to CPT, ICD-10 and HCPCS codes covers the basics.

Choosing between 97161, 97162 and 97163

Choose the evaluation level by checking four components: patient history, examination, clinical presentation and clinical decision making. APTA states that all components must be met and documented, and that the therapist must default to a lower-complexity code if one is not. The lowest component you can support sets the code.

Source: Noridian Medicare, Therapy Evaluative Procedure Codes (updated June 2025); APTA, Ringing in 2017 with New Physical Therapy Evaluation and Re-Evaluation Codes. Examination elements are body structures and functions, activity limitations and participation restrictions.

Clinical decision making follows the same three levels (low, moderate, high), and each tier is described as using a standardized patient assessment instrument and/or a measurable functional outcome. In practice that means the note should name the instrument or outcome measure used, not only describe the exam.

Worked examples

• Low (97161): a patient with a simple, recent ankle sprain, no personal factors or comorbidities affecting the plan, a stable presentation, and an exam covering one or two elements.
• Moderate (97162): a patient with chronic low back pain and one or two comorbidities that change the plan, an evolving presentation and an exam covering three or more elements.
• High (97163): a patient recovering from a stroke with three or more factors affecting the plan, an unstable presentation and an exam covering four or more elements.

When 97164 re-evaluation applies

97164 is for re-evaluating an established physical therapy plan of care. It requires an examination with standardized tests and measures and a revised plan of care. It is separate from a progress report and from a recertification.

Noridian says a re-evaluation is separately payable and is indicated when the clinician finds a change in condition that the plan of care did not anticipate, and that Medicare coverage guidelines must also be met (Noridian). In its review results for 97164, Noridian lists documentation that does not show a significant change in condition or unresponsiveness to therapy among the top reasons the service was denied.

• Re-evaluation (97164): a new examination with standardized tests and a revised plan of care after a change in condition. Billable when documentation and coverage support it.
• Progress report: a written summary at least once every 10 treatment days covering response to care, plans and goal updates. It is a documentation requirement, not a separate billable service.
• Recertification: a physician or non-physician practitioner review, date and signature of the plan of care at least every 90 calendar days. It is a regulatory requirement and is not billable on its own.

Choosing treatment codes after the evaluation

After the evaluation, each service is billed under the treatment code that matches what the therapist actually did, and most of those codes are timed. The two examples below are the pair that is most often mixed up.

Source: CodingAhead code pages for 97110 and 97530 (secondary reference to AMA descriptors); confirm against the current AMA CPT code set.

The difference is the aim of the work. If the purpose is to build a capacity such as strength or flexibility, 97110 describes it. If the patient is practicing a real-world functional task, 97530 describes it. The note should make that purpose visible, because a reviewer reading “exercises” cannot tell which code is supported.

Other common treatment services include manual therapy, neuromuscular re-education, gait training and self-care training (97140, 97112, 97116 and 97535). Confirm their descriptors and whether each is timed on the current CMS Annual Therapy Update and your AMA code set before building a template. Some pairs of codes are edited against each other for same-day billing. Our guide to modifiers 25 and 59 explains how distinct-service modifiers work, and the documentation must show the services were separate before one is added.

Turning minutes into units

For timed codes, Medicare counts total timed minutes for the day. Per CMS guidance on documentation, a single timed code is not billable for fewer than 8 minutes, 23 to 37 minutes supports 2 units, and 38 to 52 minutes supports 3 units (CMS MLN905365). Timed codes require direct one-on-one patient contact, and the time spent on untimed services does not count toward timed units.

A simple example: 20 minutes of therapeutic exercise plus 12 minutes of another timed service is 32 timed minutes, which falls in the 23 to 37 range and supports two units for the day. How those two units are divided between the codes follows the CMS manual’s tie-break rules, which we cover in our 8-minute rule guide. For the clinic-level view of unit math, see our physical therapy billing units guide.

Evaluation codes are not counted in 15-minute units. The descriptors list typical times of 20, 30 and 45 minutes, but those are guides to the work, not a minute count that changes the code. Medicare documentation guidance also asks for total treatment minutes for each date, including both timed and untimed services, so an evaluation and treatment on the same date should show each part clearly. Whether a payer allows both on one date can vary, so check the contract.

Modifiers on therapy claims

Medicare therapy claims use discipline and payment modifiers that tell the payer who delivered the service and under what plan. Leaving them off is a common reason for rejection.

Source: CMS Medicare Claims Processing Manual, Chapter 5; CMS Therapy Services page (CY 2026).

The KX threshold changes by calendar year, so use the figure for the date of service. Adding KX is an attestation that the record supports medical necessity, so the note must be able to back it. CQ is paired with GP, and CO is paired with GO.

What the record needs to defend the codes

The record has to show the evaluation, a plan of care, timely physician or practitioner certification, regular progress reports and the minutes behind every timed unit. These requirements come from CMS guidance for outpatient therapy documentation.

• Evaluation: signed and dated, with professional identification, and with the components that support the level billed.
• Plan of care: diagnoses, long-term goals, type of service, and the amount, frequency and duration of treatment, established before treatment starts, with some exceptions.
• Certification: dated signature or verbal order within 30 calendar days of the first treatment day, with verbal orders signed and dated within 14 calendar days. A signed plan of care covers the period until it ends or 90 calendar days, whichever is less.
• Progress reports: at least once every 10 treatment days, signed and dated.
• Time: total timed-code minutes and total treatment minutes for each date of service.

Since January 1, 2025, for therapist-established plans of care, a physician’s or non-physician practitioner’s dated written order or referral can substitute for the initial plan of care signature if the plan was not signed and returned within 30 days of the evaluation. The record must include the order or referral and evidence that the plan was delivered within those 30 days. Check your MAC’s guidance before relying on it.

Keeping codes consistent across a rehab practice

Coding accuracy is easier when claims are visible after the note is signed. A practice that sees each claim by stage, with an owner, can catch an evaluation without a modifier or a missing minutes entry before the payer does. A practice management system that tracks claims by stage is built for that kind of follow-through.

If your clinic has outgrown its internal process, outside medical billing services can review charges and modifiers before submission. Our page on billing for rehabilitation and therapy practices describes how this works for physical and occupational therapy. You can also read about strategies to grow a physical therapy practice if capacity and referrals are the larger concern.

Our recommendations

1. Document each evaluation component. Give the history factors, exam elements, presentation and the standardized instrument their own lines in the template, so the level is visible at a glance.
2. Record minutes for each timed code. A visit total is not enough once units are split between codes. Add a minutes field per service.
3. Set a progress-report reminder. Flag the tenth treatment day so the report is written on time and not rebuilt later.
4. Review modifiers before submission. Check GP, KX and CQ/CO on therapy lines as part of a pre-bill review rather than after a rejection. Our clean claims guide shows what a pre-submission check should cover.
5. Update the KX figure each January. Put the annual threshold on a checklist with the CMS therapy services page as the source.
6. Keep a payer sheet. List what each payer requires on units, modifiers and evaluation-plus-treatment on one date, and where you found it.

Bottom line

Pick the evaluation level from what the note proves, bill treatment in minutes the note can show, and put the modifiers and documentation in place before the claim leaves the clinic. If denials are the problem, our denial management services cover appeals and root-cause review, and you can see what unpaid therapy claims cost your clinic with the revenue calculator.

Frequently asked questions

What is the CPT code for a physical therapy evaluation?

There are three initial evaluation codes: 97161 for low complexity, 97162 for moderate and 97163 for high. The level depends on history, examination, clinical presentation and clinical decision making. No code is the default, and the record must support the level billed.

What is the difference between 97110 and 97530?

97110 is therapeutic exercise to build strength, endurance, range of motion and flexibility. 97530 is dynamic therapeutic activity aimed at improving functional performance. Both are timed per 15 minutes, so the note should state the purpose of the work and the minutes of direct one-on-one time for each.

When do I bill 97164?

97164 is for re-evaluating an established plan of care after a change in condition that the plan did not anticipate. It requires a new examination with standardized tests and a revised plan. A progress report, due at least every 10 treatment days, is a separate requirement and is not billed as 97164.

Are physical therapy treatment codes timed?

Codes such as 97110 and 97530 are timed and billed in 15-minute units. Medicare counts total timed minutes for the day, and at least 8 minutes of direct one-on-one care is needed for one unit. Untimed service time does not count toward timed units.

How is the CPT code different from the ICD-10 code on a therapy claim?

The CPT code describes the service performed, such as an evaluation or an exercise session. The ICD-10 diagnosis code supports why the care was needed. The plan of care must list diagnoses, so the two should agree with the record.

What does the KX modifier mean on a therapy claim?

KX attests that services above the annual threshold are medically necessary and justified in the record. CMS lists the 2026 threshold as $2,480 for PT and SLP combined. Add KX only when the documentation supports continued care.

Sources

1. Medicare Claims Processing Manual, Chapter 5 — CMS (2026 (accessed 2026-10-14))
2. Therapy services — CMS (2026)
3. Complying with Outpatient Rehabilitation Therapy Documentation Requirements (MLN905365) — CMS (2025)
4. Therapy Evaluative Procedure Codes — Noridian Healthcare Solutions (2025)
5. The Difference Between Outpatient Therapy Recertifications and Re-evaluations — Noridian Healthcare Solutions (2025)
6. CPT 97164, Therapeutic Procedure Re-Evaluation — Noridian Healthcare Solutions (2024)
7. Ringing in 2017 with New Physical Therapy Evaluation and Re-Evaluation Codes — APTA Pelvic Health (2017)
8. CPT 97110 — CodingAhead (2026)
9. CPT 97530 — CodingAhead (2026)