CPT 97542 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 • 59 - Distinct Procedural Service • GP - Services delivered under an outpatient physical therapy plan of care |
| Complexity Level | Low |
National average reimbursement for CPT 97542 by major payers:
$40.51
$32.36
$29.41
$33.85
| 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 97542 | ||||||
United | 97542 | $29.57 | 1487819082 - JESSICA TUMBLESON | 202305158 - TRIHEALTH G, LLC | OH | Occupational Therapist (225X00000X) |
United | 97542 | $28.38 | 1427359280 - ALAIN-PIERRE ELOI | 330376200 - (CA) SAN BERNARDINO MEDICAL ORTHOPAEDIC GROUP INC. | OH | Occupational Therapist (225X00000X) |
United | 97542 | $59.15 | 1528614070 - MARGARET PATTERSON | 550357057 - WHEELING HOSPITAL INC | OH | Occupational Therapist (225X00000X) |
United | 97542 | $49.84 | 1508238866 - OLIVIA WILLIAMSON | 752600873 - (TX) SHANNON CLINIC | TX | Occupational Therapist (225X00000X) |
United | 97542 | $52.18 | 1043663420 - COURTNEY BLACKSTON | 341933718 - NORTHERN OHIO MEDICAL SPECIALISTS, LLC | OH | Occupational Therapist (225X00000X) |
United | 97542 | $32.61 | 1801886767 - MARIE FIGHTMASTER | 311483173 - ORTHOALLIANCE MSO, LLC | KY | Occupational Therapist (225X00000X) |
United | 97542 | $28.82 | 1083756100 - MARTHA WHITE | 843153496 - (TX) LYMPHEDEMA THERAPY SPECIALISTS INC | TX | Occupational Therapist (225X00000X) |
United | 97542 | $31.53 | 1588906374 - ADRIEL RIVERA | 341032526 - (OH) SPECTRUM ORTHOPAEDICS, INC. | OH | Occupational Therapist (225X00000X) |
United | 97542 | $41.22 | 1104091446 - AMBER DEWEESE | 462458436 | OH | Occupational Therapist (225X00000X) |
United | 97542 | $29.57 | 1356554091 - NASH DREYER | 202305158 - TRIHEALTH G, LLC | OH | Occupational Therapist (225X00000X) |
United | 97542 | $50.88 | 1962871707 - MEGAN BECKETT | 840398876 - YAMPA VALLEY MEDICAL CENTER | OH | Occupational Therapist (225X00000X) |
United | 97542 | $77.98 | 1134697436 - BARBARA ELLEMAN | 310833936 - CHILDRENS HOSPITAL MEDICAL CENTER | OH | Pediatric Occupational Therapist (225XP0200X) |
United | 97542 | $24.12 | 1376952390 - RACHEL LEWIS | 311155352 - HOPEWELL HEALTH CENTERS INC | OH | Occupational Therapist (225X00000X) |
United | 97542 | $42.00 | 1770321804 - MEREDITH KROMALIC | 200503812 - (OH) ORTHOPEDIC ONE, INC. | OH | Occupational Therapist (225X00000X) |
United | 97542 | $42.00 | 1780153031 - TORIE SANDERS | 200503812 - (OH) ORTHOPEDIC ONE, INC. | OH | Occupational Therapist (225X00000X) |
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 97542 vs. Other Physical Medicine and Rehabilitation Evaluations Codes
The CPT 97542 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 97542 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 |
|---|---|---|
| 97537-CPT | Low | Community/Work Reintegration Training (Eg Shopping Transportation Money Management Avocational Activities And/Or Work Environment/ Modification Analysis Work Task Analysis Use Of Assistive Technology Device/ Adaptive Equipment) Direct One-On-One Contact Each 15 Minutes (Revised 01/01/13) |
| 97542-CPT | Low | Wheelchair Management/Propulsion Training |
| 97545-CPT | Low | Work Hardening/Condit Initial 2 Hrs |
| 97546-CPT | Low | Work Hardening/Conditioning; Each Additional Hour (List Separately In Addition To Code For Primary Procedure) |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 97542. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 97542 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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