CPT code 97168: OT reevaluation, established plan of care2026 Medicare rate & RVUs in Michigan
Occupational therapists report 97168 when reassessing an established plan of care after functional or medical changes warrant renewed analysis and plan revision.
Medicare pays $65.38–$67.44 for 97168 in the office in Michigan, from Rest of Michigan to Detroit, MI. Which amount applies depends on the service address.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
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On this page 9 sections
What 97168 covers
An occupational therapist reassesses a patient who already has an established plan of care when a change in function or medical status calls for renewed clinical analysis. The therapist may review the patient’s occupational and medical history, assess current performance in daily activities, and determine whether goals or interventions need revision. This service is distinct from routine treatment progress and from an initial occupational therapy evaluation that establishes the plan.
Report one reevaluation when the reassessment supports a revised plan of care; document the change prompting reassessment, findings, clinical reasoning, and any updated goals or interventions. It is a therapy service, not a separately billed professional component, so a professional-component modifier does not apply. When multiple therapy units are furnished on the same day, CMS reduces the practice expense for the second and later 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 97168 pays more and less in Michigan
| Payment locality | Office | Facility |
|---|---|---|
| Detroit, MI | $67.44 | Unavailable |
| Rest of Michigan | $65.38 | Unavailable |
How the 97168 rate is calculated
Each of 97168’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 · 97168
RVUs × geographic indexes × conversion factor
Work0.96
0.96 RVUs× 1.000 GPCI
Practice expense1.08
1.08 RVUs× 1.000 GPCI
Malpractice0.01
0.01 RVUs× 1.000 GPCI
Adjusted RVUs
2.0500
Conversion factor
$33.4009
Medicare rate
$68.47
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 97168
The CMS indicators that decide how 97168 is paid alongside other services.
CMS payment indicators · 97168
OT reevaluation, established plan of care
| 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
97168 without CQ · national office
$68.47
OT reevaluation, established plan of care
97168-CQ · Allowed amount unchanged
$68.47
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.
97168 compared with similar codes
Compare codes · National
4 codes, side by side
How to choose
- 97164PT re-evaluationEstablished plan of care
- 97164 is for physical therapy reevaluation of an established plan. Use 97168 for occupational therapy reevaluation.
- 97165OT evaluationLow complexity
- 97165 is an initial OT evaluation at low complexity. Choose 97168 when an established plan is being reassessed after a change in status.
- 97167OT evaluationHigh complexity
- 97167 is an initial OT evaluation at high complexity. Its complexity level does not make it a substitute for reevaluation of an established plan.
97168 billing questions
When should 97168 be chosen instead of an initial OT evaluation?
Use 97168 when the patient already has an established occupational therapy plan and a change in status prompts a reassessment and possible plan revision. Use an initial OT evaluation when establishing the plan of care.
How is 97168 different from physical therapy reevaluation 97164?
Both describe reevaluation of an established plan, but 97168 is for occupational therapy and 97164 is for physical therapy.
Can 97168 be reported with treatment on the same day?
A separately furnished therapy treatment may be reported when it is distinct from the reevaluation and supported by documentation. CMS reduces practice expense for the second and later therapy units furnished that day.
What documentation supports 97168?
Document the functional or medical change prompting reassessment, the therapist’s findings and analysis, and how the plan or goals were revised. Routine progress without a reevaluation and plan-of-care analysis does not support this service.
Does 97168 have a separate professional component?
No. It is a therapy service, and a professional-component modifier does not apply.
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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