Physical Therapy Evaluation price: Medicare anchor and facility lever
Anchor for Physical Therapy Evaluation - CPT 97161
$96.48
Nonfacility PFS $96.48; facility professional PFS $96.48.
A physical therapy evaluation, CPT 97161, is the first visit of a course of therapy, and its price is only the start of the total. The three evaluation complexity codes carry the same CY2026 anchor; the treatment visits that follow, billed in timed units, are what make up most of the cost.
CPT code
97161
Physical therapy evaluation: low complexity, typically 20 minutes face-to-face with the patient and/or family
CPT 97161 is a low-complexity physical therapy evaluation. Moderate complexity is 97162 and high complexity is 97163, both published at the same CY2026 PAR amount in the WPS file for Michigan Locality 01. Treatment units after the evaluation (for example 97110) bill separately.
The codes this visit can be billed under
| CPT | PFS office or global | PFS facility (professional) | Global period | Hospital single-service APC | Minimum Medicare copay at hospital |
|---|---|---|---|---|---|
| 97161 (this page) | $96.48 | $96.48 | not a surgical global | not paid by APC | n/a |
| 97162 | $96.48 | $96.48 | not a surgical global | not paid by APC | n/a |
| 97163 | $96.48 | $96.48 | not a surgical global | not paid by APC | n/a |
The CY2026 Michigan Locality 01 anchor for 97161 is $96.48, and the moderate (97162) and high (97163) complexity evaluations carry the identical amount. In a hospital outpatient department therapy is still paid under the fee schedule, which is why the OPPS Addendum B shows no APC for these codes.
Because later visits are billed per unit of timed treatment, two clinics with the same evaluation price can produce very different totals over a course of care. Ask each clinic for its price per visit for the treatment codes it expects to use, and how many visits it expects to schedule.
For a Medicare patient, outpatient therapy is a Part B service, so coinsurance applies to each evaluation and visit after the Part B deductible. Because the CY2026 anchor for all three evaluation codes is the same, $96.48, the complexity level on the bill does not change the Medicare anchor for the first visit. Treatment visits that follow are where the total builds.
Inside and outside the 97161 anchor
Covered by the anchor
- Physical therapist evaluation at the low-complexity level (PFS anchor below)
- Standard assessment instruments and the written plan of care
Billed outside it
- Treatment units on the same or later visits (for example 97110 therapeutic exercise)
- Re-evaluation billed under 97164 when performed on a later date
- The referring visit and any imaging billed separately
Why prices vary for CPT 97161
Outpatient therapy is paid under the Physician Fee Schedule even in a hospital outpatient department, so there is no separate OPPS facility anchor for this code. Cash prices still vary because clinics set their own per-visit rates and because the number of treatment units after the evaluation drives the total. Price the evaluation and the expected per-visit cost together.
Ask whether therapy will be in a hospital outpatient department or an independent clinic, how the evaluation is billed, and what each treatment visit will cost after the evaluation. Get the per-visit cash price in writing.
Questions specific to PT evaluation
- What is the price of the evaluation, and is it the same for every complexity level?
- What treatment codes are expected after the evaluation, and what is the price per unit?
- How many visits are expected, and is there a package price?
- Is the clinic hospital-owned, and does that add any facility line?
Physical Therapy Evaluation: billing questions
Does a more complex PT evaluation cost more?
Not under the CY2026 Medicare fee schedule for Michigan Locality 01: 97161, 97162 and 97163 carry the same anchor. A clinic's own cash prices may still differ by level, so ask.
Why is the evaluation price only part of the cost?
Treatment after the evaluation is billed per visit, usually in timed units. The number of visits and units decides the total more than the evaluation does.
Is physical therapy in a hospital paid under OPPS?
No. Outpatient therapy is paid under the Physician Fee Schedule even in a hospital outpatient department, so there is no OPPS facility anchor for these codes.
Is there a separate hospital facility charge for therapy in a hospital department?
Not under OPPS. The CY2026 OPPS Addendum B lists the evaluation codes with a status for services paid under a fee schedule rather than an APC, so therapy in a hospital outpatient department is paid under the Physician Fee Schedule. Ask the clinic whether it adds any other charge.