CPT code 97167: OT evaluation, high complexity2026 Medicare rate & RVUs

Medicare pays $100.54 for 97167 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 97167 covers

An occupational therapist uses this evaluation to examine how a person’s health conditions affect daily activities, roles, and participation. It may involve a detailed occupational profile, review of relevant medical and therapy history, assessment of multiple areas of functional performance, and development of an individualized plan of care. Examples include evaluating a person after a stroke whose motor, cognitive, and self-care limitations interact with other clinical concerns. The CMS short descriptor identifies a 60-minute service, but complexity—not elapsed time alone—distinguishes this level.

Select the level from the documented occupational profile and history, performance deficits, assessment findings, and clinical decision-making demands. The record should support why the evaluation required high-complexity analysis and how findings informed the plan of care. Report one evaluation service rather than timed units. This is a therapy service, so a professional-component modifier does not apply. When multiple therapy units are billed for the same day, Medicare reduces practice expense 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 97167 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

97167 rates by state

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

How the 97167 rate is calculated

Each of 97167’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 97167

The CMS indicators that decide how 97167 is paid alongside other services.

What modifiers do to the payment

97167 compared with similar codes

How to choose

97166OT evaluationModerate complexity

Choose 97166 when the documented evaluation supports moderate rather than high complexity. Do not select between the levels based only on visit duration.

97165OT evaluationLow complexity

Choose 97165 for a low-complexity OT evaluation; 97167 requires documentation supporting high-complexity assessment and decision making.

97168OT reevaluationEstablished plan of care

97168 is for reassessment of an established OT plan of care, while 97167 represents an initial OT evaluation.

97163PT evaluationHigh complexity

97163 is the high-complexity physical therapy evaluation. Use 97167 for an occupational therapy evaluation.

Codes related to 97167

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