CPT 97161 cost and Medicare rate
For code 97161, evaluation for physical therapy, Medicare's 2026 rate nationally is about $98. In 2024, providers nationally typically billed about $193. Medicare rates are a common benchmark, not what every plan pays.
What CPT 97161 is
Evaluation for physical therapy, typically 20 minutes.
Office is the rate when the service is done in a clinic, office or imaging center, and covers the whole service. Facility is the doctor's part when it is done in a hospital or surgery center, which bills its own facility fee separately. The hospital outpatient rate is Medicare's rate for that facility fee.
What Medicare pays for 97161 nationally
| Setting | Medicare 2026 | Medicare allowed 2024 | Typically billed 2024 |
|---|---|---|---|
| Office or clinic | $97.86 | $99.47 | $192.71 |
Medicare 2026 is the national fee schedule rate (conversion factor 33.4009). "Medicare allowed" and "typically billed" are averages from Medicare claims in 2024.
97161 by state
Where you were treated changes the benchmark. Medicare's 2026 rate depends on the pricing area. The table shows the rest-of-state rate and the range across each state's pricing areas; some big cities have their own, higher rate. Billed amounts are what providers typically billed in an office or clinic in 2024.
| State and Medicare pricing area | Office 2026 | Office range in state | Typically billed 2024 |
|---|---|---|---|
| California Rest of California | $103.01 | $103.01 to $123.74 29 pricing areas | $178.40 |
| New York Rest of New York | $95.46 | $95.46 to $110.15 5 pricing areas | $196.77 |
| Texas Rest of Texas | $95.48 | $93.69 to $100.60 8 pricing areas | $192.64 |
| Florida Rest of Florida | $96.00 | $96.00 to $100.27 3 pricing areas | $222.97 |
| Illinois Rest of Illinois | $94.04 | $94.04 to $99.73 4 pricing areas | $202.93 |
| Ohio Statewide | $93.86 | One rate statewide | $175.74 |
| Georgia Rest of Georgia | $92.95 | $92.95 to $98.82 2 pricing areas | $196.83 |
| Washington Rest of Washington | $100.90 | $100.90 to $110.84 2 pricing areas | $186.48 |
| Pennsylvania Rest of Pennsylvania | $94.07 | $94.07 to $100.74 2 pricing areas | $198.69 |
| Arizona Statewide | $96.39 | One rate statewide | $194.82 |
What your charge for 97161 means
Med Bill Check compares a charge with Medicare's rate and with what providers typically billed. Here is how it reads three national charges:
- Charged $100: Your $100 is close to the Medicare rate, which is a good sign. Medicare rates are a common benchmark, not what every plan pays.
- Charged $200: Your $200 is about 2 times the Medicare rate, and close to what providers typically billed. That is a common benchmark rather than a verdict, and asking for an itemized bill or a self-pay discount is a sensible next step.
- Charged $390: Your $390 is about 4 times the Medicare rate and 2 times what providers typically billed. That is a common benchmark rather than a verdict, and asking for an itemized bill or a self-pay discount is a sensible next step.
Medicare rates are a common benchmark, not what every plan or provider charges, and never proof a bill is wrong. Enter your own charge and state on the home page for your figures.
Common billing questions for 97161
- Units: Medicare's automated limit for 97161 is 1 unit for one patient on one day (NCCI Medically Unlikely Edits). If your bill shows more, ask them to confirm the units. Medicare limits (MUE) are the most units Medicare pays automatically for one patient on one day. Going over is a reason to ask, not proof of an error, since some cases are allowed with records.
- Duplicates and services you did not get: Look for duplicate lines, services you did not receive, and unit counts that look high.
How to question a charge for 97161
- Ask for an itemized bill with codes, units and prices. Itemized bill letter.
- Compare each line with your Explanation of Benefits if you have insurance.
- Ask the billing office to review the charge in writing, and to hold the account from collections meanwhile. Charge review letter.
- Ask for a prompt-pay or self-pay discount, or an interest-free payment plan. Discount letter.
- If it was a hospital, ask for its financial assistance policy. Financial assistance letter and which hospitals must offer it.
With your code and amount, the review letter adds the benchmark for you, for example: For reference, Medicare's 2026 fee schedule rate for code 97161 nationally is about $98, and Medicare's published data shows providers nationally typically billed about $193 in 2024.
Keep a copy of everything you send, and note the date and the name of anyone you speak to. If you have insurance, call your insurer too. They can check whether the claim was processed correctly.
Quick answers
- What is CPT 97161?
- Evaluation for physical therapy, typically 20 minutes.
- How much does Medicare pay for 97161 in 2026?
- Nationally, Medicare's 2026 rate is $97.86 in an office or clinic.
- What do providers typically charge for 97161?
- In 2024, providers nationally typically billed $192.71 for 97161 in an office or clinic.
- Is $390 for 97161 too much?
- Your $390 is about 4 times the Medicare rate and 2 times what providers typically billed. That is a common benchmark rather than a verdict, and asking for an itemized bill or a self-pay discount is a sensible next step.
- How much is 97161 in Texas?
- For code 97161, evaluation for physical therapy, Medicare's 2026 rate in Texas is about $95. In 2024, providers in Texas typically billed about $193. Medicare rates are a common benchmark, not what every plan pays.
- How many units of 97161 can be billed in one day?
- Medicare's automated limit is 1 for one patient on one day. Going over is a reason to ask, not proof of an error, since some cases are allowed with records.
Sources
- CMS Medicare Physician Fee Schedule, 2026 (pfs.data.cms.gov)
- CMS Medicare Physician and Other Practitioners by Geography and Service, 2024 data (data.cms.gov)
- CMS NCCI Medically Unlikely Edits, effective 2026-10-01
General information, not medical, legal or financial advice. Medicare rates are a common benchmark, not what every plan or provider charges. For your own bill, check with the billing office, your insurer or your doctor.
Ask Med Bill Check yourself
Enter the code or the service in plain words, your state and what you were charged, and see how it compares with Medicare's rate. Open Med Bill Check, free, no sign-up.
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