CPT 97166 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 | • GO - Services delivered under an outpatient occupational therapy plan of care • None • KX - Requirements specified in the medical policy have been met |
| Complexity Level | Moderate |
National average reimbursement for CPT 97166 by major payers:
$93.91
$91.75
$93.98
$110.36
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
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CPT 97166 vs. Other Physical Medicine and Rehabilitation Evaluations Codes
The CPT 97166 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 97166 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 |
|---|---|---|
| 97165 | 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 | 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 |
| 97167 | Low | Occupational Therapy Evaluation High Complexity Requiring These Components:An Occupational Profileand Medical And Therapy History Which Includes Review Of Medical And/Or Therapy Records And Extensive Additional Review Of Physical Cognitiveor Psychosooial History Related To Current Func- Tional Performance; An Assessment(S) That Identi- Fies 5 Or More Performance Deficits (Ie Relating To Physical Cognitive Or Psychosocial Skills) That Result In Activity Limitations And/Or |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 97166. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 97166 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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Medicare Reimbursement Lookup Tool
Medicare localities are geographic regions used to adjust reimbursement rates based on local costs. Rates vary by locality to reflect differences in wages, rent, and other expenses. Sign up to see commercial rates (United/BCBS/Cigna/Aetna)
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| Year | Billing Code | Locality | Non-Facility Fee | Facility Fee |
|---|