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See a sample rate comparisonCPT 97165 Fee Schedule
Last Verified: October 2026
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
Ot Eval Low Complex 30 Min, Occupational Therapy Evaluation Low Complexity Requiring These Components An Occupational Profile And Medical And Therapy History Which Includes A Brief History Including Review Of Medical And Or Therapy Records Relating To The Presenting Problem An Assessment S That Identifies 1 3 Performance Deficits Ie Relating To Physical Cognitive Or Psychosocial Skills That Result In Activity Limitations And Or Participation Restrictions And Clinical Decision Making Of Low Complexity Which Includes An Analysis Of The Occupational Profile Analysis Of Data From Problem Focused Assessment S And Consideration Of A Limited Number Of Treatment Options Patient Presents With No Comorbidities That Affect Occupational Performance Modification Of Tasks Or Assistance Eg Physical Or Verbal With Assessment S Is Not Necessary To Enable Completion Of Evaluation Component Typically 30 Minutes Are Spent Face To Face With The Patient And Or Family
| Key Fact | Detail |
|---|---|
| Service Type | Medicine Services and Procedures Physical Medicine and Rehabilitation Evaluations |
| Common Place of Service | 11 - Office |
| Common Modifiers | GO - Services delivered under an outpatient occupational therapy plan of care 59 - Distinct Procedural Service |
| Complexity Level | Low |
| Medicare Fee Schedule | $100.54 national non-facility rate (2026) · View Medicare rates for 97165 |
| Medicaid Fee Schedule | $81.47 median of the 7 states in the free preview · View Medicaid rates for 97165 |
National average reimbursement for CPT 97165 by major payers:
$93.89
$91.90
$93.82
$109.85
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CPT 97165
5 of 25 sample ratesHigher to lower in this preview
Jonathan Jezequel
Caremount Medical, P.C.
$246.69Published rateChristian Olivares Physical Therapy Services PC
$88.00Published rateAmira Lisle
Sports Physical Therapy Occupationa Therapy And Rehabilitation Service
$88.00Published rateMichael Schmutter
Bienetre Medical PC
$79.13Published rateErin Harbison
$55.86Published rate
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See a sample payer proposalCPT 97165 vs. Other Physical Medicine and Rehabilitation Evaluations Codes
The CPT 97165 code is part of the Medicine Services and Procedures services used for Physical Medicine and Rehabilitation Evaluations. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 97165 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 97164-CPT | Low | Pt Re Eval Est Plan Care, Re Evaluation Of Physical Therapy Established Plan Of Care Requiring These Components An Examination Including A Review Of History And Use Of Standardized Tests And Measures Is Required And Revised Plan Of Care Using A Standardized Patient Assessment Instrument And Or Measurable Assessment Of Functional Outcome Typically 20 Minutes Are Spent Face To Face With The Patient And Or Family |
| 97165-CPT | Low | Ot Eval Low Complex 30 Min, Occupational Therapy Evaluation Low Complexity Requiring These Components An Occupational Profile And Medical And Therapy History Which Includes A Brief History Including Review Of Medical And Or Therapy Records Relating To The Presenting Problem An Assessment S That Identifies 1 3 Performance Deficits Ie Relating To Physical Cognitive Or Psychosocial Skills That Result In Activity Limitations And Or Participation Restrictions And Clinical Decision Making Of Low Complexity Which Includes An Analysis Of The Occupational Profile Analysis Of Data From Problem Focused Assessment S And Consideration Of A Limited Number Of Treatment Options Patient Presents With No Comorbidities That Affect Occupational Performance Modification Of Tasks Or Assistance Eg Physical Or Verbal With Assessment S Is Not Necessary To Enable Completion Of Evaluation Component Typically 30 Minutes Are Spent Face To Face With The Patient And Or Family |
| 97166-CPT | Low | Ot Eval Mod Complex 45 Min, Occupational Therapy Evaluation Moderate Complexity Requiring These Components An Occupational Profile And Medical And Therapy History Which Includes An Expanded Review Of Medical And Or Therapy Records And Additional Review Of Physical Cognitive Or Psychosocial History Related To Current Functional Performance An Assessment S That Identifies 3 5 Performance Deficits Ie Relating To Physical Cognitive Or Psychosocial Skills That Result In Activity Limitations And Or Participation Restrictions And Clinical Decision Making Of Moderate Analytic Complexity Which Includes An Analysis Of The Occupational Profile Analysis Of Data From Detailed Assessment S And Consideration Of Several Treatment Options Patient May Present With Comorbidities That Affect Occupational Performance Minimal To Moderate Modification Of Tasks Or Assistance Eg Physical Or Verbal With Assessment S Is Necessary To Enable Patient To Complete Evaluation Component Typically 45 Minutes Are Spent Face To Face With The Patient And Or Family |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 97165. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 97165 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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Frequently Asked Questions
The cost of medical procedures can vary significantly based on location, provider, and insurance plan. For an estimate of specific procedure costs based on CPT codes and your location, you can use tools like Payerprice's fee schedule lookup tool. It allows you to search for pricing information to help you understand potential costs for your specific situation.
CPT stands for Current Procedural Terminology. CPT codes are a set of medical codes used by healthcare providers to describe medical, surgical, and diagnostic services to entities such as insurers, patients, and accreditation organizations. They are essential for accurate billing and processing of claims.
A fee schedule is a comprehensive listing of fees used by health insurers to determine the maximum amount they will reimburse providers for a particular service or procedure. These schedules can vary based on the insurer, the specific plan, and the geographic location.
Medical costs vary due to numerous factors, including the specific healthcare provider (e.g., hospital vs. independent clinic), geographic location, insurance negotiation, complexity of the procedure, and whether the provider is in-network or out-of-network. Tools like Payerprice aim to help consumers navigate these variations by providing transparent pricing information.
Payerprice is a service that provides a fee schedule lookup tool. It allows users to search for medical procedure costs using CPT codes and specific locations, helping them understand potential healthcare expenses.
Payerprice can help you by providing access to fee schedule information for specific medical procedures based on CPT codes and your location. This allows you to research and compare potential costs before receiving care, helping you make more informed healthcare decisions and potentially plan for expenses.
Your medical bill is typically sent directly to you by your healthcare provider or hospital after you receive services. It may come via mail or be accessible through an online patient portal. If you haven't received it, contact the billing department of the provider directly.
If you believe your medical bill is incorrect, the first step is to contact the billing department of the healthcare provider or hospital immediately to request an itemized bill and clarify any charges. You can also compare the services listed with your Explanation of Benefits (EOB) from your insurance company. For information on typical costs for services to compare against your bill, tools like Payerprice can be useful for researching procedure costs based on CPT codes and your location.