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 | Physical Medicine and Rehabilitation Therapeutic 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 | Low |
| Medicare Fee Schedule | View Medicare rates for 97166 |
National average reimbursement for CPT 97166 by major payers:
$93.91
$91.75
$93.98
$109.85
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
United | 97166 | $101.66 | 1114592649 - RASIKA HATTI | 922142300 | NY | Physical Therapist (225100000X) |
United | 97166 | $88.00 | 1114516606 - RYAN OOMMEN | 61655704 - (NY) SPORTS PHYSICAL THERAPY OCCUPATIONA THERAPY AND REHABILITATION SERVICE | NY | Physical Therapist (225100000X) |
United | 97166 | $54.77 | 1548711815 - MATTHEW TURTURRO | 815250608 - (NY) EDEN HEALTH MEDICAL PC | NY | Physical Therapist (225100000X) |
United | 97166 | $209.19 | 1174179048 - SERENITY SERAFINI | 916001537 | NY | Physical Therapist (225100000X) |
United | 97166 | $88.00 | 1316553654 - ROSANGELIS RODRIGUEZ | 131740114 - MONTEFIORE MEDICAL CENTER | NY | Physical Therapist (225100000X) |
United | 97166 | $88.00 | 1669401717 - L I PHYSICAL THERAPY & WELLNESS PLLC | 113558943 - (NY) LONG ISLAND PHYSICAL THERAPY | NY | Physical Therapist (225100000X) |
United | 97166 | $145.47 | 1457478893 - JAMES WU | 135562308 - NEW YORK UNIVERSITY | NY | Speech-Language Pathologist (235Z00000X) |
United | 97166 | $88.00 | 1316093693 - MAGIC HANDS PHYSICAL THERAPY PLLC | 582682136 - (NY) MAGIC HANDS PHYSICAL THERAPY PLLC | NY | Physical Therapy Clinic/Center (261QP2000X) |
United | 97166 | $88.00 | 1710634829 - SOUNDPORT PT, PC, <UNAVAIL> | 300064124 - (NY) SOUNDSIDE PHYSICAL THERAPY PC | NY | Physical Therapist (225100000X) |
United | 97166 | $172.07 | 1295201549 - JESSE KOTLER | 453023019 - (NY) NORTH SHORE-LIJ MEDICAL PC | NY | Speech-Language Pathologist (235Z00000X) |
United | 97166 | $84.88 | 1306155619 - KRISTINA CARRACCIA | 141395426 - (NY) THE CENTER FOR DISCOVERY INC | NY | Speech-Language Pathologist (235Z00000X) |
United | 97166 | $88.00 | 1336408269 - INTEGRATED REHAB & PHYSICAL THERAPY P.C. | 271726076 - (NY) INTEGRATED REHAB PHYSICAL THERAPY PC | NY | Physical Therapy Clinic/Center (261QP2000X) |
United | 97166 | $59.08 | 1356829667 - PRUTHVI THAKAR | 131974191 - (NY) BRONXCARE HEALTH SYSTEM | NY | Physical Therapist (225100000X) |
United | 97166 | $80.87 | 1669011953 - ALNAWAZ BABWANI | 421571876 - (NY) JERICHO ROAD MINISTRIES | NY | Physical Therapist (225100000X) |
United | 97166 | $90.50 | 1619246618 - DESIREE FERRER | 201049779 - (NY) VICTORIA PHYSICAL MEDICINE PC | 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 97166 vs. Other Physical Medicine and Rehabilitation Evaluations Codes
The CPT 97166 code is part of the Physical Medicine and Rehabilitation Therapeutic 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-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 |
| 97167-CPT | Low | Ot Eval High Complex 60 Min, Occupational Therapy Evaluation High Complexity Requiring These Components An Occupational Profile And Medical And Therapy History Which Includes Review Of Medical And Or Therapy Records And Extensive Additional Review Of Physical Cognitive Or Psychosocial History Related To Current Functional Performance An Assessment S That Identifies 5 Or More Performance Deficits Ie Relating To Physical Cognitive Or Psychosocial Skills That Result In Activity Limitations And Or Participation Restrictions And Clinical Decision Making Of High Analytic Complexity Which Includes An Analysis Of The Patient Profile Analysis Of Data From Comprehensive Assessment S And Consideration Of Multiple Treatment Options Patient Presents With Comorbidities That Affect Occupational Performance Significant Modification Of Tasks Or Assistance Eg Physical Or Verbal With Assessment S Is Necessary To Enable Patient To Complete Evaluation Component Typically 60 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 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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