How to Use and Bill CPT Code 97162 in Physical Therapy: The 2025 Guide

Understanding how to properly use and bill CPT code 97162 can make a measurable difference in a physical therapy clinic’s compliance, reimbursement, and overall patient outcomes. The difference between a clean claim and a denied one often lies in documentation accuracy, code selection, and understanding how the 97162 CPT code description translates to real-world evaluations.

This guide walks through every aspect — when to use it, how to document it, what’s changing in 2025, and how to avoid costly mistakes when billing for 97162 CPT code physical therapy sessions.

What Is CPT Code 97162

Let’s start simple. CPT code 97162 represents a moderate complexity physical therapy evaluation. Think of it as the middle ground between basic and high-complexity assessments:

• 97161 CPT code: Low complexity

• 97162 CPT code: Moderate complexity

• 97163 CPT code: High complexity

In most cases, a CPT 97162 evaluation involves around 30 minutes of face-to-face time with the patient. But keep in mind — this isn’t just about duration. It’s about clinical complexity and the therapist’s level of reasoning required to design an effective plan of care.

Learn more about how physical therapy CPT codes work across different service levels.

97162 CPT Code Description

According to the official 97162 CPT code description, the evaluation includes:

• Review of the patient’s medical and therapy history

• Assessment of three or more body systems (for example, balance, strength, coordination, or gait)

• Identification of one or two comorbidities or personal factors that influence recovery

• Moderate-level clinical decision-making that drives the treatment plan

So when you use the 97162 CPT code for physical therapy, you’re documenting a patient case that requires more consideration and evaluation than a simple injury or stable post-op situation, but not as complex as a severe or unstable case.

When Should You Use CPT Code 97162

The CPT 97162 should be used when a patient’s condition involves moderate complexity—more than a basic assessment, but not high-risk or unpredictable.

Criteria for 97162 CPT code physical therapy

• Evaluation of three or more body systems, such as flexibility, strength, balance, and range of motion

• Consideration of one or two comorbidities or personal factors (e.g., diabetes, obesity, or arthritis)

• Moderate-level clinical decision-making, based on multiple findings and evolving symptoms

Practical examples include

• A post-surgical knee patient with early-stage diabetes

• A middle-aged individual with chronic lower back pain and mild obesity

• An older adult struggling with both gait instability and muscle weakness

In each of these examples, the patient’s presentation requires thoughtful analysis and adaptation, making CPT code 97162 the right billing choice.

What Documentation Is Required for CPT Code 97162

If you want to get reimbursed without delays—or worse, avoid claim denials—documentation must clearly support the 97162 CPT code description.

Your notes should include

• Patient History: Document at least one or two personal factors or comorbidities, such as obesity, diabetes, or a previous injury.

• Examination Findings: Evaluate three or more body systems or functions, which might include range of motion, flexibility, strength, endurance, balance, coordination, gait, mobility, and neuromuscular assessments.

• Clinical Decision-Making: Explain how findings influenced your plan. The complexity of your reasoning is what justifies the use of the 97162 CPT code.

• Plan of Care: Define measurable goals that relate directly to your assessment results. Describe why certain interventions are chosen over others.

• Medical Necessity: Show why the therapy is necessary and appropriate. Each intervention must be defensible in your notes—especially when billing CPT code 97162 physical therapy for moderate complexity.

Read more about preparing and organizing your documentation for accurate physical therapy billing.

Common Mistakes to Avoid with 97162 CPT Code

Here are the main pitfalls that lead to rejections, denials, and audit headaches:

Using 97162 Just Because You Spent 30 Minutes

Time matters, but it’s not the main qualifier. Use 97162 only if clinical complexity fits all criteria.​

Over-Documenting Basic Cases

Even if your notes are pages long, that doesn’t make the eval moderate. The clinical scenario and decisions must justify the code.​

Missing Personal Factors or Comorbidities

If you don’t document at least one or two, your claim might get rejected or downgraded.​

Forgetting to Justify the Plan of Care

You need more than a list of exercises—show why you chose those interventions with supporting clinical logic tied directly to your evaluation findings.​

Steer clear of these pitfalls to keep your 97162 CPT code compliant and your reimbursements steady. Check out this related post on how incorrect PT documentation can lead to major CMS penalties.

Why Using 97162 Correctly Is So Important

Correctly applying CPT 97162 isn’t just about compliance—it’s about accuracy, professionalism, and financial health.

Here’s what correct coding does for your practice:

• Prevents payment delays and denials

• Strengthens audit protection

• Ensures fair compensation

• Reflects your true clinical expertise

• Improves continuity of care and outcome tracking

In short, proper use of the 97162 CPT code physical therapy ensures your records match the care you deliver.

What’s New in the 2025 Guidelines for CPT 97162?

CPT coding isn't static. For 2025, the 97162 CPT description features tighter standards, especially around what constitutes moderate complexity. Here’s what you need to know:

1. Detailed Documentation Standards

To comply with the 2025 rules, you must show:

• A patient history that is thorough and explicitly covers all comorbidities and personal influences.

• Objective assessment of at least three body systems or functions (both in your exam and your notes).

• Moderately complex decision-making, tied to evolving patient presentation and clear documentation of why lesser or greater complexity codes didn't fit.

• Specific, measurable goals, directly linked to your findings.

Vague language like improve strength and flexibility is no longer enough. You’ll need to show, for example, why specific balance training is prescribed and how results will be measured.​

2. Insurance & Reimbursement Updates

Insurers are now putting 97162 under the microscope:

• Carriers are auditing and denying claims at higher rates for weak or incomplete documentation.

• They want proof for every specific element—if you miss just one, your claim is at risk.

• Appeals processes have become more rigorous, with clinics required to show clear compliance with moderate complexity requirements.​

Read more to understand how the 8-minute rule applies to Medicare billing and why mastering these timing guidelines is key to accurate reimbursements in physical therapy sessions.

3. Training and Compliance

Staying up-to-date means:

• Training your staff on the new documentation requirements using coding checklists.

• Running internal audits before claims go out the door.

• Consulting coding and billing specialists or using advanced EHR systems with integrated claim tools to boost compliance and accuracy.​

Summary Table: Key 2025 Changes

Category	2025 Update Summary
Documentation	Must be highly detailed, proving every moderate complexity element
Insurance Scrutiny	Higher risk of audits and denials if documentation is incomplete or ambiguous
Staff Training	Ongoing education and monthly internal reviews are required for full compliance
Coding Resources	Use up-to-date checklists and coding experts to avoid billing and coding errors

Real-World Story: Jane’s 97162 Evaluation

Jane, a physical therapist, met Robert, a 60-year-old stroke survivor who wanted to regain his balance and strength.

During the evaluation, she assessed three systems: balance, gait, and muscle strength.

She also identified two comorbidities—arthritis and diabetes—that made his recovery more complex. As Robert’s fatigue set in, Jane adjusted the session in real-time, showing the moderate clinical decision-making that defines CPT code 97162.

Her goals were clear and measurable: improve balance to prevent falls and rebuild stair-climbing ability within eight weeks. The 30-minute session met all the CPT 97162 physical therapy requirements. When billed, the claim was processed quickly, proving that accurate documentation leads to timely payment and better patient outcomes.

FAQ

1. What are the CPT code 97162 billing guidelines?

CPT code 97162 covers a moderate-complexity physical therapy evaluation. Bill it only when documentation shows assessment of three body systems and moderate clinical decision-making.

2. How to bill a physical therapy evaluation?

Accurately document patient history, comorbidities, and evaluation complexity. Choose the correct CPT—97161, 97162, or 97163—based on case severity, then submit claims with supporting notes for reimbursement.

3. What is the difference between 97161 and 97162?

CPT 97161 represents low-complexity evaluations involving stable conditions, while 97162 applies to moderate complexity cases requiring assessment of three systems and one or two personal factors or comorbidities.

Conclusion

CPT code 97162 isn’t just a billing code—it represents your clinic’s accuracy, ethics, and quality of care. When used correctly, it ensures fair reimbursement and stronger patient outcomes.

To stay compliant and maximize your revenue, make sure your team fully understands the requirements for CPT code 97162 physical therapy. Regularly review documentation practices, follow the latest 2025 CPT updates, and stay consistent with staff training and internal audits.

If you’re uncertain about coding or compliance standards, consult a certified coding specialist. A little diligence now can prevent denials, protect your clinic during audits, and keep your documentation audit-ready all year long.