97164 with Medicare: what the policy says
The short answerYes, but not routinely. Medicare pays 97164 at about $67.47 nationally in 2026, and NCCI wants modifier 59 or XU with a documented status change when it is billed alongside treatment.
By Javier Alvarez · Updated · 1 min read
1 row: Medicare. Public policy, not the member's benefits.
Medicare
Original Medicare (Part B), outpatient physical therapy · All states
| 97110 | Listed (timed, 15 minutes per unit) [1][2] |
|---|---|
| 97112 | Listed (timed, 15 minutes per unit) [1] |
| 97140 | Listed (timed, 15 minutes per unit) [1] |
| 97161 | Listed (evaluation, low complexity. One unit per episode of care.) [1][3] |
| 97162 | Listed (evaluation, moderate complexity. One unit per episode of care.) [1] |
| 97163 | Listed (evaluation, high complexity. One unit per episode of care.) [1] |
| 97164 | Limited (re-evaluation. Not routine during a planned course of therapy; use modifier 59 or XU only if the patient status changes.) [1][3] |
| 97530 | Listed (timed, 15 minutes per unit) [1] |
| Where it applies | Original Medicare Part B pays for outpatient physical therapy under a plan of care. Every therapy claim must carry the GP modifier to show it is a physical therapy plan of care. [2] |
| Other codes | Also priced in the 2026 file: 97164 re-evaluation, 97116 gait training, 97535 self-care training, 97542 wheelchair management and 97750 physical performance test. Remote therapeutic monitoring codes 98976, 98977, 98979, 98984 and 98985 are sometimes-therapy codes. [1][4] |
| Telehealth POS | Use POS 02 for telehealth when the patient is not at home and POS 10 when the patient is at home. Telehealth to a patient at home pays at the non-facility rate. [5] |
| Telehealth rules | Physical therapists can furnish Medicare telehealth, including the telephone assessment and management codes, through December 31, 2027. From January 1, 2028 they can no longer furnish Medicare telehealth under current law. Audio-only is allowed for patients in their homes through December 31, 2027. [4][5] |
| Visit limits | For 2026 the KX modifier threshold is $2,480 a year for PT and speech-language pathology combined (OT has its own $2,480). Claims above it without KX are denied. The targeted medical review threshold stays at $3,000 until 2028. [6][4] |
| Referral | A physician or NPP must certify the plan of care. Initial certification is due within 30 calendar days of the first treatment day, and recertification at least every 90 calendar days or when the plan changes significantly. Since January 1, 2025 a dated written order or referral can stand in for the signature on the initial plan if the signed plan is not returned in 30 days and the chart shows the plan was delivered. [2] |
| Who can bill | A physical therapist can bill Medicare directly after enrolling as a private practitioner (solo, partnership, group, physician or NPP group, or an incorporated therapy practice). Services go in the therapist's or group's office or in the patient's home. [7] |
| Payment | 2026 national amounts calculated from the CMS RVU file (total non-facility RVUs x $33.4009 conversion factor, before locality adjustment and the multiple procedure reduction): 97110 $29.06, 97112 $32.73, 97140 $27.72, 97530 $35.07, 97161 to 97163 $97.87 each, 97164 $67.47. [1] |
| Medicare rules | When a physical therapist assistant furnishes more than 10% of a service on their own, add CQ next to GP. Medicare pays CQ claims at 85% of the usual Part B amount. Do not use CQ when the PT does the whole service or when the PT and PTA treat together at the same time. [2] |
| Also | Timed codes follow the 8-minute rule: a single unit needs at least 8 minutes, and 23 minutes is the minimum for 2 units. The second and later therapy services on the same day get 50% of the practice expense component (MPPR). A progress report is needed at least once every 10 treatment days. [2][4] |
- CMS: PFS Relative Value Files, RVU26D (updated 08-26-2026), file PPRRVU2026_Oct_nonQPP, checked October 30, 2026
- CMS: MLN905365, Complying with Outpatient Rehabilitation Therapy Documentation Requirements (September 2025, PDF), checked October 30, 2026
- CMS: NCCI Medicare Policy Manual 2026, Chapter XI Medicine and E/M, 90000-99999 (rev. 1/1/2026, PDF), checked October 30, 2026
- CMS: Therapy Services landing page, CY 2026 Therapy Services Updates (KX threshold, MPPR, CQ/CO, telehealth), checked October 30, 2026
- CMS: Telehealth FAQ, updated 10/8/26 (PDF), checked October 30, 2026
- CMS: Transmittal 13437 (Change Request 14252) / Transmittal 13437, 2026 Annual Update of KX Modifier Thresholds (Oct 30, 2025, PDF), checked October 30, 2026
- CMS: Medicare Benefit Policy Manual, Chapter 15 (Rev. 13889, issued 07-30-26, PDF), checked October 30, 2026
What Medicare's policy says about 97164
97164 is the CPT code for physical therapy re-evaluation. At Medicare it is limited: paid only in a narrow case, see the note. Each line below is from the cited text:
- Where it is listed. 97164 is an active code on the 2026 Medicare fee schedule, valued at 2.02 total non-facility RVUs. (CMS, checked October 30, 2026)
- When it pays. NCCI has edits pairing treatment codes with 97164. Re-evaluation is not reported routinely during a planned course. If the patient status changes and a re-evaluation is medically necessary, append modifier 59 or XU. (CMS, checked October 30, 2026)
- Units. No more than one unit of 97164 per date of service. (CMS, checked October 30, 2026)
- Payment. 2026 national amount calculated from the CMS file: 2.02 x $33.4009 = $67.47. (CMS, checked October 30, 2026)
The rest of Medicare's physical therapy rules
The Medicare row has its codes, telehealth rule, limits and authorization, each with its source. Other codes we checked at Medicare: 97112, 97140 and 97161. Before the claim goes out, compare it with the row in the table above.