CPT 97165 Fee Schedule
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.
| Key Fact | Detail |
|---|---|
| Service Type | • Medicine Services and Procedures • Physical Medicine and Rehabilitation Evaluations |
| Common Place of Service | • 11 - Office • None |
| Common Modifiers | • None • GO - Services delivered under an outpatient occupational therapy plan of care • 59 - Distinct Procedural Service |
| Complexity Level | Low |
National average reimbursement for CPT 97165 by major payers:
$93.89
$91.90
$93.82
$110.36
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
Select a payer to view fee schedule data Choose a payer from the options above to see rates for CPT 97165 | ||||||
United | 97165 | $84.00 | 1699404889 - RESOLUTE PHYSICAL THERAPY PLLC | 882491925 - (NY) RESOLUTE PHYSICAL THERAPY PLLC | NY | Physical Therapy Clinic/Center (261QP2000X) |
United | 97165 | $93.11 | 1578110821 - SARAH BOGDANOVITCH | 42121377 - THE SHRINERS HOSPITAL FOR CHILDREN | NY | Speech-Language Pathologist (235Z00000X) |
United | 97165 | $76.69 | 1902921919 - MARC DEPERNO | 223100745 - (NY) CHARLES T SITRIN HEALTH CARE CENTER INC | NY | Occupational Therapist (225X00000X) |
United | 97165 | $67.55 | 1023184199 - JOSEPH SARACENO | 270242223 | NY | Physical Therapist (225100000X) |
United | 97165 | $117.91 | 1831201300 - JOANN DISTASI | 61043480 - (CT) ORTHOPAEDIC & NEUROSURGERY SPECIALISTS, PC | NY | Hand Occupational Therapist (225XH1200X) |
United | 97165 | $152.46 | 1780095455 - SYRACUSE ORTHOPEDIC SPECIALISTS, PC | 160992982 - (NY) SYRACUSE ORTHOPEDIC SPECIALISTS, PC | NY | Physical Therapist (225100000X) |
United | 97165 | $129.22 | 1033170345 - MATTHEW LUMLEY | 141338544 - SAMARITAN HOSPITAL | NY | Physical Therapist (225100000X) |
United | 97165 | $85.87 | 1225697741 - JONG MOON KIM | 113616414 - (NY) PREMIUM MEDICAL CARE, P.C. | NY | Physical Therapist (225100000X) |
United | 97165 | $79.13 | 1093583262 - TEJASHREE RAO | 863716253 - (NY) BIENETRE MEDICAL PC | NY | Physical Therapist (225100000X) |
United | 97165 | $95.54 | 1699073577 - PAGE BAKER | 384015271 | NY | Physical Therapist (225100000X) |
United | 97165 | $94.73 | 1255368171 - ANN LEITTEN | 160975538 - (NY) PEOPLE INC | NY | Occupational Therapist (225X00000X) |
United | 97165 | $93.45 | 1568686426 - ELI FONTANILLA | 522229826 - (MD) CENTENNIAL MEDICAL GROUP INC | MD | Physical Therapist (225100000X) |
United | 97165 | $55.00 | 1407511009 - TAE KYUNG LEE | 61081232 - (NY) MORRIS HEIGHTS HEALTH CENTER INC | NY | Occupational Therapist (225X00000X) |
United | 97165 | $88.00 | 1578758066 - KIDS IN SHAPE PHYSICAL THERAPY LLC | 651258165 - (NY) KIDS IN SHAPE PHYSICAL THERAPY LLC | NY | Physical Therapist (225100000X) |
United | 97165 | $363.88 | 1194463075 - ALEXIS VALERA | 131740114 - MONTEFIORE MEDICAL CENTER | NY | Physical Therapist (225100000X) |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
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CPT 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 | Re-Evaluation Of Physical Therapy Established Planof Care Requiring These Components: An Examina- Tionincluding A Review Of History And Use Of Standardized Tests And Measures Is Required;And Revised Plan Of Care Using Standardized Patient Assessment Instrument And/Or Measurable Assessmentof Functional Outcome Typically 20 Minutes Are Spent Face-To -Face With The Patient And/Or Family |
| 97165-CPT | Low | Occupational Therapy Evaluation Low Complexity Requiring These Components: An Occupational Pro- File And Medical And Therapy History Which In- Cludes A Brief History Including Review Of Medicaland/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 Restric-Tions; And Clinical Decision Making A Low Complex- |
| 97166-CPT | Low | Occupational Therapy Evaluation Moderate Comp- Lexity Requiring These Components: An Occupation-Al Profile And Medical And Therapy History Whichincludes 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 Re- Lating To Physical Cognitive Or Psychosocial Skills) That Result In Activity Limitations |
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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