Billing code 97166: OT evaluationMedicare rate & RVUs

Medicare pays $100.54 for 97166 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 97166 covers

An occupational therapist evaluates how a health condition affects the patient’s daily activities, such as dressing, bathing, meal preparation, work, or home tasks. The evaluation may include an expanded occupational profile and review of medical or therapy history, assessment of functional performance, and clinical decision-making. Moderate complexity is supported by 3–5 performance deficits and a moderate level of analytic decision-making; comorbidities may affect performance, and evaluation may require minimal to moderate task modification or assistance. Common settings include outpatient therapy clinics, hospitals, and rehabilitation facilities.

Select this level from the documented history, deficits, decision-making, and assistance or task modification required—not from diagnosis alone. The note should support the occupational profile, relevant findings, evaluation complexity, and plan of care. The code represents one evaluation, with 45 minutes reflected in its descriptor; it is not billed in timed treatment increments. CMS treats it as a therapy service, so a professional-component modifier does not apply. Under the therapy multiple procedure payment reduction, the practice-expense portion is reduced for the second and later therapy units on the same day.

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 97166 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

97166 rates by state

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

How the 97166 rate is calculated

Each of 97166’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 97166

The CMS indicators that decide how 97166 is paid alongside other services.

What modifiers do to the payment

97166 compared with similar codes

How to choose

97165OT evaluation

Choose 97165 for low-complexity evaluation; 97166 reflects moderate complexity, including the supported number of deficits and level of clinical decision-making.

97167OT evaluation

Choose 97167 when the evaluation supports high complexity rather than moderate complexity, based on the documented profile, deficits, decision-making, and assistance or task modification.

97168OT reevaluation

97168 describes re-evaluation of an established plan of care. Use 97166 for a moderate-complexity initial evaluation, not a re-evaluation.

Codes related to 97166

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