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See a sample rate comparisonCPT 97167 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 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
| 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 KX - Requirements specified in the medical policy have been met |
| Complexity Level | Low |
| Medicare Fee Schedule | $100.54 national non-facility rate (2026) · View Medicare rates for 97167 |
| Medicaid Fee Schedule | $85.00 median of the 7 states in the free preview · View Medicaid rates for 97167 |
National average reimbursement for CPT 97167 by major payers:
$94.35
$91.76
$92.24
$109.88
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CPT 97167
5 of 25 sample ratesHigher to lower in this preview
Lauren Schumacher
$546.28Published rateMarissa Carraway
Crouse Radiology Associates LLP / East Carolina University / Ecu Medicine Neurology Mri
$144.94Published rateNeve Inc, Avada Audiology & Hearing Care
$92.65Published rateChristopher Johnson
Southern Illinois Healthcare Foundation Inc
$77.47Published rateGiselle Aquino
$35.00Published rate
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See a sample payer proposalCPT 97167 vs. Other Physical Medicine and Rehabilitation Evaluations Codes
The CPT 97167 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 97167 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 |
|---|---|---|
| 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 |
| 97168-CPT | Low | Ot Re Eval Est Plan Care, Re Evaluation Of Occupational Therapy Established Plan Of Care Requiring These Components An Assessment Of Changes In Patient Functional Or Medical Status With Revised Plan Of Care An Update To The Initial Occupational Profile To Reflect Changes In Condition Or Environment That Affect Future Interventions And Or Goals And A Revised Plan Of Care A Formal Reevaluation Is Performed When There Is A Documented Change In Functional Status Or A Significant Change To The Plan Of Care Is Required Typically 30 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 97167. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 97167 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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