CPT code 97165: OT evaluation, low complexity2026 Medicare rate & RVUs

Medicare pays $100.54 for 97165 nationally in the office. Local office rates run $93.50–$129.28.

Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.

What 97165 covers

An occupational therapist evaluates how a patient performs daily activities, such as dressing, bathing, cooking, or using the hands for work and self-care. The therapist gathers a focused occupational profile and relevant medical or therapy history, identifies performance problems, and determines whether skilled occupational therapy is appropriate. Evaluations commonly take place in outpatient clinics, rehabilitation settings, or other locations where occupational therapy is provided.

Choose this level when the evaluation involves low-complexity clinical decision making, a limited number of performance deficits, and few needed modifications to the assessment. Document the profile and history reviewed, functional findings, clinical reasoning, and resulting plan of care. The code identifies an evaluation service, not a unit selected by elapsed treatment time. Medicare treats it as a therapy service rather than separate professional and technical claims. When multiple therapy services are furnished on the same day, practice expense is reduced for the second and later therapy units.

This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.

Where 97165 pays more and less

The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.

109 of 109 payment localities

97165 rates by state

Office rate range in each state. Select a state to see its payment localities.

How the 97165 rate is calculated

Each of 97165’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.

Payment rules and modifiers for 97165

The CMS indicators that decide how 97165 is paid alongside other services.

What modifiers do to the payment

97165 compared with similar codes

How to choose

97166OT evaluationModerate complexity

Use 97166 when the occupational therapy evaluation supports moderate rather than low clinical decision-making complexity.

97167OT evaluationHigh complexity

Use 97167 for a high-complexity occupational therapy evaluation; 97165 represents the low-complexity level.

97168OT reevaluationEstablished plan of care

Use 97168 for reevaluation of an established occupational therapy plan of care, rather than an initial low-complexity evaluation.

97161PT evaluationLow complexity, typically 20 minutes

97161 is a low-complexity physical therapy evaluation. Choose 97165 when the evaluated service is occupational therapy.

Codes related to 97165

Related codes aren’t interchangeable: bill the code that matches the service performed.

Where these rates come from

FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.

CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027

Open CMS sourceHow we calculate rates