CPT code 97167: OT evaluation, high complexity2026 Medicare rate & RVUs in South Carolina
Report this code for a high-complexity occupational therapy evaluation involving extensive assessment of occupational performance and complex clinical decision making.
In South Carolina, Medicare pays $96.78 for 97167 in the office.
Check a contract rate as a % of Medicare · 97167 nationwide
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 11 sections
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.
How South Carolina compares for 97167
Across 109 of 109 payment localities, the office rate for 97167 runs from $93.50 in Arkansas to $129.28 in Alaska. South Carolina pays $96.78. The RVUs are the same everywhere; the geographic indexes change the dollars.
- South Carolina · this page$96.78
- Los Angeles, CA · California$111.46+$14.68
- Washington, DC area · District of Columbia$112.03+$15.25
- Miami, FL · Florida$103.05+$6.27
- Chicago, IL · Illinois$101.57+$4.79
- Manhattan, NY · New York$111.92+$15.14
- Alaska · Alaska$129.28+$32.50
Other areas in South Carolina first, then benchmark localities. Bars start at $0.
Every other payment area
| Payment locality | Office | Facility |
|---|---|---|
| AlabamaAlabama | $94.30 | — |
| ArkansasArkansas | $93.50 | — |
| ArizonaArizona | $98.98 | — |
| Bakersfield, CACalifornia | $106.06 | — |
| Chico, CACalifornia | $105.94 | — |
| El Centro, CACalifornia | $105.94 | — |
| Fresno, CACalifornia | $105.94 | — |
| Hanford, CACalifornia | $105.94 | — |
| Madera, CACalifornia | $105.94 | — |
| Merced, CACalifornia | $105.94 | — |
| Modesto, CACalifornia | $105.94 | — |
| Napa, CACalifornia | $119.12 | — |
| Oxnard, CACalifornia | $110.73 | — |
| Redding, CACalifornia | $105.94 | — |
| Rest of CaliforniaCalifornia | $105.94 | — |
| Riverside, CACalifornia | $106.09 | — |
| Sacramento, CACalifornia | $110.18 | — |
| Salinas, CACalifornia | $109.73 | — |
| San Diego, CACalifornia | $111.48 | — |
| Marin County, CACalifornia | $125.24 | — |
| San Francisco, CACalifornia | $125.22 | — |
| San Benito County, CACalifornia | $127.59 | — |
| Santa Clara County, CACalifornia | $127.55 | — |
| San Luis Obispo, CACalifornia | $108.03 | — |
| Santa Cruz, CACalifornia | $111.95 | — |
| Santa Maria, CACalifornia | $109.92 | — |
| Santa Rosa, CACalifornia | $113.04 | — |
| Stockton, CACalifornia | $105.94 | — |
| Vallejo, CACalifornia | $119.10 | — |
| Visalia, CACalifornia | $105.94 | — |
| Yuba City, CACalifornia | $105.94 | — |
| ColoradoColorado | $104.20 | — |
| ConnecticutConnecticut | $105.39 | — |
| DelawareDelaware | $100.17 | — |
| Fort Lauderdale, FLFlorida | $101.44 | — |
| Rest of FloridaFlorida | $98.56 | — |
| Atlanta, GAGeorgia | $101.54 | — |
| Rest of GeorgiaGeorgia | $95.33 | — |
| Hawaii, Guam, HIHawaii | $107.08 | — |
| IowaIowa | $96.19 | — |
| IdahoIdaho | $96.46 | — |
| East St. Louis, ILIllinois | $96.97 | — |
| Rest of IllinoisIllinois | $96.48 | — |
| Suburban Chicago, ILIllinois | $102.47 | — |
| IndianaIndiana | $96.81 | — |
| KansasKansas | $95.69 | — |
| KentuckyKentucky | $95.10 | — |
| New Orleans, LALouisiana | $97.70 | — |
| Rest of LouisianaLouisiana | $94.91 | — |
| Metropolitan Boston, MAMassachusetts | $112.07 | — |
| Rest of MassachusettsMassachusetts | $103.88 | — |
| Baltimore area, MDMaryland | $105.00 | — |
| Rest of MarylandMaryland | $101.61 | — |
| Rest of MaineMaine | $96.51 | — |
| Southern Maine, MEMaine | $99.97 | — |
| Detroit, MIMichigan | $99.06 | — |
| Rest of MichiganMichigan | $96.34 | — |
| MinnesotaMinnesota | $101.72 | — |
| Metropolitan Kansas City, MOMissouri | $97.55 | — |
| Metropolitan St. Louis, MOMissouri | $98.20 | — |
| Rest of MissouriMissouri | $93.80 | — |
| MississippiMississippi | $93.67 | — |
| MontanaMontana | $100.54 | — |
| North CarolinaNorth Carolina | $97.15 | — |
| North DakotaNorth Dakota | $100.34 | — |
| NebraskaNebraska | $96.57 | — |
| New HampshireNew Hampshire | $102.49 | — |
| Northern New JerseyNew Jersey | $111.60 | — |
| Rest of New JerseyNew Jersey | $107.11 | — |
| New MexicoNew Mexico | $96.56 | — |
| NevadaNevada | $100.53 | — |
| NYC suburbs and Long Island, NYNew York | $113.33 | — |
| Poughkeepsie and northern NYC suburbs, NYNew York | $107.55 | — |
| Queens, NYNew York | $112.85 | — |
| Rest of New YorkNew York | $98.00 | — |
| OhioOhio | $96.30 | — |
| OklahomaOklahoma | $95.24 | — |
| Portland, OROregon | $106.69 | — |
| Rest of OregonOregon | $100.24 | — |
| Metropolitan Philadelphia, PAPennsylvania | $103.53 | — |
| Rest of PennsylvaniaPennsylvania | $96.52 | — |
| Puerto RicoPuerto Rico | $101.07 | — |
| Rhode IslandRhode Island | $103.09 | — |
| South DakotaSouth Dakota | $100.31 | — |
| TennesseeTennessee | $95.94 | — |
| Austin, TXTexas | $103.43 | — |
| Beaumont, TXTexas | $96.12 | — |
| Brazoria, TXTexas | $100.44 | — |
| Dallas, TXTexas | $100.76 | — |
| Fort Worth, TXTexas | $100.27 | — |
| Galveston, TXTexas | $100.55 | — |
| Houston, TXTexas | $100.73 | — |
| Rest of TexasTexas | $98.02 | — |
| UtahUtah | $97.58 | — |
| VirginiaVirginia | $99.61 | — |
| Virgin Islands, VIUnited States Virgin Islands | $101.07 | — |
| VermontVermont | $99.88 | — |
| Rest of WashingtonWashington | $103.71 | — |
| King County, WAWashington | $114.12 | — |
| WisconsinWisconsin | $98.26 | — |
| West VirginiaWest Virginia | $94.29 | — |
| WyomingWyoming | $100.45 | — |
97167 rates by state
Office rate range in each state. Select a state to see its payment localities.
Explore a state
Local rates. Clear comparisons.
Hover or focus a tile to see its rate range. Select it to open the state’s fee schedule.
$93.50
$129.28
Color shows the midpoint of each state’s locality range.
View every state and territory as a table
| State / territory | Office rate range | Localities |
|---|---|---|
| AK | $129.28 | 1 |
| AL | $94.30 | 1 |
| AR | $93.50 | 1 |
| AZ | $98.98 | 1 |
| CA | $105.94–$127.59 | 29 |
| CO | $104.20 | 1 |
| CT | $105.39 | 1 |
| DC | $112.03 | 1 |
| DE | $100.17 | 1 |
| FL | $98.56–$103.05 | 3 |
| GA | $95.33–$101.54 | 2 |
| GU | $107.08 | 1 |
| HI | $107.08 | 1 |
| IA | $96.19 | 1 |
| ID | $96.46 | 1 |
| IL | $96.48–$102.47 | 4 |
| IN | $96.81 | 1 |
| KS | $95.69 | 1 |
| KY | $95.10 | 1 |
| LA | $94.91–$97.70 | 2 |
| MA | $103.88–$112.07 | 2 |
| MD | $101.61–$112.03 | 3 |
| ME | $96.51–$99.97 | 2 |
| MI | $96.34–$99.06 | 2 |
| MN | $101.72 | 1 |
| MO | $93.80–$98.20 | 3 |
| MS | $93.67 | 1 |
| MT | $100.54 | 1 |
| NC | $97.15 | 1 |
| ND | $100.34 | 1 |
| NE | $96.57 | 1 |
| NH | $102.49 | 1 |
| NJ | $107.11–$111.60 | 2 |
| NM | $96.56 | 1 |
| NV | $100.53 | 1 |
| NY | $98.00–$113.33 | 5 |
| OH | $96.30 | 1 |
| OK | $95.24 | 1 |
| OR | $100.24–$106.69 | 2 |
| PA | $96.52–$103.53 | 2 |
| PR | $101.07 | 1 |
| RI | $103.09 | 1 |
| SC | $96.78 | 1 |
| SD | $100.31 | 1 |
| TN | $95.94 | 1 |
| TX | $96.12–$103.43 | 8 |
| UT | $97.58 | 1 |
| VA | $99.61–$112.03 | 2 |
| VI | $101.07 | 1 |
| VT | $99.88 | 1 |
| WA | $103.71–$114.12 | 2 |
| WI | $98.26 | 1 |
| WV | $94.29 | 1 |
| WY | $100.45 | 1 |
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.
How the rate is built · 97167
RVUs × geographic indexes × conversion factor
Work1.54
1.54 RVUs× 1.000 GPCI
Practice expense1.46
1.46 RVUs× 1.000 GPCI
Malpractice0.01
0.01 RVUs× 1.000 GPCI
Adjusted RVUs
3.0100
Conversion factor
$33.4009
Medicare rate
$100.54
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
The exact South Carolina inputs and CMS source lines
PPRRVU2026_Oct_nonQPP.csv
12,883
- Code
- 97167
- Physician work
- 1.54
- Practice expense
- 1.46
- Malpractice
- 0.01
GPCI2026.csv
93
- Locality
- South Carolina
- Physician work
- 1.000
- Practice expense
- 0.924
- Malpractice
- 0.850
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 1.54 | × 1.000 | 1.5400 |
| Practice expense | 1.46 | × 0.924 | 1.3490 |
| Malpractice | 0.01 | × 0.850 | 0.0085 |
| Total RVUs | 2.8975 | ||
| Conversion factor | × 33.4009 | ||
Office rate, South Carolina$96.78
Office: (1.54 × 1 + 1.46 × 0.924 + 0.01 × 0.85) × $33.4009 = $96.78
Payment rules and modifiers for 97167
The CMS indicators that decide how 97167 is paid alongside other services.
CMS payment indicators · 97167
OT evaluation, high complexity
| Rule | CMS value | What it means |
|---|---|---|
| Global period | XXX | The global surgery concept doesn’t apply. |
| Multiple procedures | 5 | Therapy reduction: practice expense of the second and later units is reduced. |
| Bilateral (modifier 50) | 0 | The 150% bilateral adjustment doesn’t apply. |
| Assistant at surgery (80/81/82/AS) | 0 | Not paid without supporting documentation. |
| Co-surgeons (62) | 0 | Not permitted. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 7 | Therapy service: the split doesn’t apply. |
What modifiers do to the payment
Modifier CQ · payment effect
With and without the modifier
97167 without CQ · national office
$100.54
OT evaluation, high complexity
97167-CQ · Allowed amount unchanged
$100.54
Medicare cuts its own payment by 15% after the patient’s 20% coinsurance; the allowed amount stays the same. On $100 allowed: $20 coinsurance, then Medicare pays $68 instead of $80.
How 97167 has changed in South Carolina
97167 · Office / nonfacility
$96.78
Effective 2026-10-01
The base rate is $0.72 higher than on 2025-10-01, moving from $96.06 to $96.78 (0.7%).
It is unchanged from the immediately preceding available release, effective 2026-07-01.
One bar per available release, ordered by effective date. Missing rates remain gaps. These comparisons hold the code, setting and locality identifiers constant; they do not isolate which policy or input caused a change.
What changed, release by release
January 1, 2026
RVU26A
$96.06changed to$96.78
- Conversion factor 32.3465 changed to 33.4009
- Practice expense RVU 1.53 changed to 1.46
- Malpractice RVU 0.04 changed to 0.01
- Practice expense GPCI 0.913 changed to 0.924
- Malpractice GPCI 0.817 changed to 0.850
Held through RVU26B, RVU26C, RVU26D.
January 1, 2025
RVU25A
$96.72changed to$96.06
- Conversion factor 33.2875 changed to 32.3465
- Practice expense RVU 1.46 changed to 1.53
Held through RVU25B, RVU25C, RVU25D.
March 9, 2024
RVU24AR
$95.14changed to$96.72
- Conversion factor 32.7442 changed to 33.2875
Held through RVU24B, RVU24C, RVU24D.
January 1, 2024
RVU24A
$96.90changed to$95.14
- Conversion factor 33.8872 changed to 32.7442
- Practice expense RVU 1.42 changed to 1.46
- Practice expense GPCI 0.908 changed to 0.913
- Malpractice GPCI 0.756 changed to 0.817
January 1, 2023
RVU23A
$97.79changed to$96.90
- Conversion factor 34.6062 changed to 33.8872
- Practice expense RVU 1.37 changed to 1.42
- Malpractice RVU 0.07 changed to 0.04
- Practice expense GPCI 0.903 changed to 0.908
- Malpractice GPCI 0.695 changed to 0.756
Held through RVU23B, RVU23C, RVU23D.
January 1, 2022
RVU22A
$94.02changed to$97.79
- Conversion factor 34.8931 changed to 34.6062
- Practice expense RVU 1.24 changed to 1.37
- Malpractice RVU 0.05 changed to 0.07
Held through RVU22B, RVU22C, RVU22D.
January 1, 2021
RVU21A
$87.64changed to$94.02
- Conversion factor 36.0896 changed to 34.8931
- Work RVU 1.20 changed to 1.54
- Practice expense RVU 1.32 changed to 1.24
- Practice expense GPCI 0.907 changed to 0.903
- Malpractice GPCI 0.624 changed to 0.695
Held through RVU21B, RVU21C, RVU21D.
January 1, 2020
RVU20A
$87.96changed to$87.64
- Conversion factor 36.0391 changed to 36.0896
- Practice expense RVU 1.33 changed to 1.32
- Practice expense GPCI 0.912 changed to 0.907
- Malpractice GPCI 0.553 changed to 0.624
Held through RVU20B, RVU20C, RVU20D.
January 1, 2019
RVU19A
$87.53changed to$87.96
- Conversion factor 35.9996 changed to 36.0391
- Practice expense RVU 1.32 changed to 1.33
Held through RVU19B, RVU19C, RVU19D.
January 1, 2018
RVU18AR1
$88.55changed to$87.53
- Conversion factor 35.8887 changed to 35.9996
- Malpractice RVU 0.10 changed to 0.05
- Malpractice GPCI 0.634 changed to 0.553
Held through RVU18B, RVU18C, RVU18D.
April 1, 2017
RVU17B
$75.13changed to$88.55
- Practice expense RVU 0.91 changed to 1.32
Held through RVU17C, RVU17D.
January 1, 2017
RVU17A
No ratechanged to$75.13
January 1, 2013
RVU13AR
Earliest loaded release: No rate
Held through RVU13B, RVU13C, RVU13D, RVU14A, RVU14B, RVU14C, RVU14D, RVU15A, RVU15B, RVU15C, RVU15D, RVU16A, RVU16B, RVU16C, RVU16D.
| Effective from | Office | Facility | CMS release |
|---|---|---|---|
| 2026-10-01 | $96.78 | Not available in this setting | RVU26D |
| 2026-07-01 | $96.78 | Not available in this setting | RVU26C |
| 2026-04-01 | $96.78 | Not available in this setting | RVU26B |
| 2026-01-01 | $96.78 | Not available in this setting | RVU26A |
| 2025-10-01 | $96.06 | Not available in this setting | RVU25D |
| 2025-07-01 | $96.06 | Not available in this setting | RVU25C |
| 2025-04-01 | $96.06 | Not available in this setting | RVU25B |
| 2025-01-01 | $96.06 | Not available in this setting | RVU25A |
| 2024-10-01 | $96.72 | Not available in this setting | RVU24D |
| 2024-07-01 | $96.72 | Not available in this setting | RVU24C |
| 2024-04-01 | $96.72 | Not available in this setting | RVU24B |
| 2024-03-09 | $96.72 | Not available in this setting | RVU24AR |
| 2024-01-01 | $95.14 | Not available in this setting | RVU24A |
| 2023-10-01 | $96.90 | Not available in this setting | RVU23D |
| 2023-07-01 | $96.90 | Not available in this setting | RVU23C |
| 2023-04-01 | $96.90 | Not available in this setting | RVU23B |
| 2023-01-01 | $96.90 | Not available in this setting | RVU23A |
| 2022-10-01 | $97.79 | Not available in this setting | RVU22D |
| 2022-07-01 | $97.79 | Not available in this setting | RVU22C |
| 2022-04-01 | $97.79 | Not available in this setting | RVU22B |
| 2022-01-01 | $97.79 | Not available in this setting | RVU22A |
| 2021-10-01 | $94.02 | Not available in this setting | RVU21D |
| 2021-07-01 | $94.02 | Not available in this setting | RVU21C |
| 2021-04-01 | $94.02 | Not available in this setting | RVU21B |
| 2021-01-01 | $94.02 | Not available in this setting | RVU21A |
| 2020-10-01 | $87.64 | Not available in this setting | RVU20D |
| 2020-07-01 | $87.64 | Not available in this setting | RVU20C |
| 2020-04-01 | $87.64 | Not available in this setting | RVU20B |
| 2020-01-01 | $87.64 | Not available in this setting | RVU20A |
| 2019-10-01 | $87.96 | Not available in this setting | RVU19D |
| 2019-07-01 | $87.96 | Not available in this setting | RVU19C |
| 2019-04-01 | $87.96 | Not available in this setting | RVU19B |
| 2019-01-01 | $87.96 | Not available in this setting | RVU19A |
| 2018-10-01 | $87.53 | Not available in this setting | RVU18D |
| 2018-07-01 | $87.53 | Not available in this setting | RVU18C |
| 2018-04-01 | $87.53 | Not available in this setting | RVU18B |
| 2018-01-01 | $87.53 | Not available in this setting | RVU18AR1 |
| 2017-10-01 | $88.55 | Not available in this setting | RVU17D |
| 2017-07-01 | $88.55 | Not available in this setting | RVU17C |
| 2017-04-01 | $88.55 | Not available in this setting | RVU17B |
| 2017-01-01 | $75.13 | Not available in this setting | RVU17A |
| 2016-10-01 | Not in this release | Not in this release | RVU16D |
| 2016-07-01 | Not in this release | Not in this release | RVU16C |
| 2016-04-01 | Not in this release | Not in this release | RVU16B |
| 2016-01-01 | Not in this release | Not in this release | RVU16A |
| 2015-10-01 | Not in this release | Not in this release | RVU15D |
| 2015-07-01 | Not in this release | Not in this release | RVU15C |
| 2015-04-01 | Not in this release | Not in this release | RVU15B |
| 2015-01-01 | Not in this release | Not in this release | RVU15A |
| 2014-10-01 | Not in this release | Not in this release | RVU14D |
| 2014-07-01 | Not in this release | Not in this release | RVU14C |
| 2014-04-01 | Not in this release | Not in this release | RVU14B |
| 2014-01-01 | Not in this release | Not in this release | RVU14A |
| 2013-10-01 | Not in this release | Not in this release | RVU13D |
| 2013-07-01 | Not in this release | Not in this release | RVU13C |
| 2013-04-01 | Not in this release | Not in this release | RVU13B |
| 2013-01-01 | Not in this release | Not in this release | RVU13AR |
Where the South Carolina rate applies
South Carolina is a Medicare payment area, not a city. Our Census mapping connects it to 475 cities and communities in South Carolina. Some span more than one payment area; confirm with the service ZIP.
- Abbeville
- Abney Crossroads
- Adams Run
- Aiken
- Alcolu
- Allendale
- Anderson
- Andrews
97167 billing questions
How is this code distinguished from the moderate-complexity OT evaluation?
Use this level when the documented profile, functional assessment, and clinical decision making support high complexity rather than moderate complexity. The 60-minute descriptor alone does not establish the level.
Is the evaluation billed in 15-minute units?
No. Report the evaluation as one service, not as timed units. The 60-minute figure is part of the CMS short descriptor.
Can a professional-component modifier be appended?
No. CMS identifies this as a therapy service for which the professional-component modifier does not apply.
What documentation supports high complexity?
Document the occupational profile and relevant history, assessed performance deficits, clinical findings, decision-making demands, and how the evaluation supports the plan of care.
What happens when other therapy units are billed on the same day?
Medicare reduces practice expense for the second and later therapy units billed that day. The reduction applies to therapy units, not by converting this evaluation into timed units.
When should an OT re-evaluation be reported instead?
Use the OT re-evaluation code when reassessing an established plan of care, rather than conducting an initial evaluation.
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
Show the CMS file lines behind this rate
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