$93.50–$129.28
Choose 97166 when the documented evaluation supports moderate rather than high complexity. Do not select between the levels based only on visit duration.
On this page
CMS RVU26D · Effective 2026-10-01
97167 OT evaluation Medicare reimbursement rates
Report this code for a high-complexity occupational therapy evaluation involving extensive assessment of occupational performance and complex clinical decision making. Compare 97167 office and facility rates across CMS payment localities.
Amounts below use the non-QP conversion factor for participating physicians. These are base physician payments before claim-level adjustments, not patient costs or total hospital charges.
What does Medicare pay for 97167?
The service location and office or facility setting determine which base rate applies. These are the supported base rates for the 109 payment areas shown below, using the same CMS release.
Office / nonfacility
$93.50–$129.28
109 of 109 localities have a supported rate.
Facility setting
No supported rate
These are locality ranges, not averages or address-specific quotes. A facility-setting amount covers the physician service; it does not include a hospital’s separate bill. Choose a locality below to inspect its calculation, compare other payment areas, or price a percentage of Medicare.
Where 97167 pays more and less
109 payment localities
$93.50 to $129.28
Occupational therapy
About 97167: High-complexity occupational therapy evaluation
Report this code for a high-complexity occupational therapy evaluation involving extensive assessment of occupational performance and complex clinical decision making.
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.
CMS billing rules for 97167
- Professional and technical components
- Therapy service: the professional component modifier does not apply.
- Multiple procedures
- Therapy multiple procedure payment reduction: practice expense is reduced for the second and later therapy units on the same day.
Where the value comes from
- Work RVU1.54 · 51%
- Practice expense (office) RVU1.46 · 49%
- Malpractice RVU0.01 · 0%
26.8K
Medicare services in 2024 · #1017 by national volume
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.
97167 compared with similar codes
Office rate ranges across all CMS payment localities, from the same CMS release.
$93.50–$129.28
Choose 97165 for a low-complexity OT evaluation; 97167 requires documentation supporting high-complexity assessment and decision making.
$63.22–$87.79
97168 is for reassessment of an established OT plan of care, while 97167 represents an initial OT evaluation.
$91.20–$126.43
97163 is the high-complexity physical therapy evaluation. Use 97167 for an occupational therapy evaluation.
See how rates vary across the country
97167 · Office / nonfacility · Non-QP. Choose a state to explore its payment localities. A range means the amount varies within that state.
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 all state and territory rates as a table
| State / territory | 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 |
Compare 97167 by payment locality
Find the payment area for your service address, then open its rate page for calculation inputs, release history and the percentage-of-Medicare tool. A city may cross payment-area boundaries; the ZIP lookup above helps resolve the location.
109 of 109 payment localities
| Payment locality | Office | Facility |
|---|---|---|
| Alabama | Office $94.30 | Facility Unavailable |
| Alaska* | Office $129.28 | Facility Unavailable |
| Arizona | Office $98.98 | Facility Unavailable |
| Arkansas | Office $93.50 | Facility Unavailable |
| Atlanta | Office $101.54 | Facility Unavailable |
| Austin | Office $103.43 | Facility Unavailable |
| Bakersfield | Office $106.06 | Facility Unavailable |
| Baltimore/Surr. Cntys | Office $105.00 | Facility Unavailable |
| Beaumont | Office $96.12 | Facility Unavailable |
| Brazoria | Office $100.44 | Facility Unavailable |
| Chicago | Office $101.57 | Facility Unavailable |
| Chico | Office $105.94 | Facility Unavailable |
| Colorado | Office $104.20 | Facility Unavailable |
| Connecticut | Office $105.39 | Facility Unavailable |
| Dallas | Office $100.76 | Facility Unavailable |
| Dc + Md/Va Suburbs | Office $112.03 | Facility Unavailable |
| Delaware | Office $100.17 | Facility Unavailable |
| Detroit | Office $99.06 | Facility Unavailable |
| East St. Louis | Office $96.97 | Facility Unavailable |
| El Centro | Office $105.94 | Facility Unavailable |
| Fort Lauderdale | Office $101.44 | Facility Unavailable |
| Fort Worth | Office $100.27 | Facility Unavailable |
| Fresno | Office $105.94 | Facility Unavailable |
| Galveston | Office $100.55 | Facility Unavailable |
| Hanford-Corcoran | Office $105.94 | Facility Unavailable |
| Hawaii, Guam | Office $107.08 | Facility Unavailable |
| Houston | Office $100.73 | Facility Unavailable |
| Idaho | Office $96.46 | Facility Unavailable |
| Indiana | Office $96.81 | Facility Unavailable |
| Iowa | Office $96.19 | Facility Unavailable |
| Kansas | Office $95.69 | Facility Unavailable |
| Kentucky | Office $95.10 | Facility Unavailable |
| Los Angeles-Long Beach-Anaheim (Los Angeles/Orange Cnty) | Office $111.46 | Facility Unavailable |
| Madera | Office $105.94 | Facility Unavailable |
| Manhattan | Office $111.92 | Facility Unavailable |
| Merced | Office $105.94 | Facility Unavailable |
| Metropolitan Boston | Office $112.07 | Facility Unavailable |
| Metropolitan Kansas City | Office $97.55 | Facility Unavailable |
| Metropolitan Philadelphia | Office $103.53 | Facility Unavailable |
| Metropolitan St. Louis | Office $98.20 | Facility Unavailable |
| Miami | Office $103.05 | Facility Unavailable |
| Minnesota | Office $101.72 | Facility Unavailable |
| Mississippi | Office $93.67 | Facility Unavailable |
| Modesto | Office $105.94 | Facility Unavailable |
| Montana** | Office $100.54 | Facility Unavailable |
| Napa | Office $119.12 | Facility Unavailable |
| Nebraska | Office $96.57 | Facility Unavailable |
| Nevada** | Office $100.53 | Facility Unavailable |
| New Hampshire | Office $102.49 | Facility Unavailable |
| New Mexico | Office $96.56 | Facility Unavailable |
| New Orleans | Office $97.70 | Facility Unavailable |
| North Carolina | Office $97.15 | Facility Unavailable |
| North Dakota** | Office $100.34 | Facility Unavailable |
| Northern Nj | Office $111.60 | Facility Unavailable |
| Nyc Suburbs/Long Island | Office $113.33 | Facility Unavailable |
| Ohio | Office $96.30 | Facility Unavailable |
| Oklahoma | Office $95.24 | Facility Unavailable |
| Oxnard-Thousand Oaks-Ventura | Office $110.73 | Facility Unavailable |
| Portland | Office $106.69 | Facility Unavailable |
| Poughkpsie/N Nyc Suburbs | Office $107.55 | Facility Unavailable |
| Puerto Rico | Office $101.07 | Facility Unavailable |
| Queens | Office $112.85 | Facility Unavailable |
| Redding | Office $105.94 | Facility Unavailable |
| Rest Of California | Office $105.94 | Facility Unavailable |
| Rest Of Florida | Office $98.56 | Facility Unavailable |
| Rest Of Georgia | Office $95.33 | Facility Unavailable |
| Rest Of Illinois | Office $96.48 | Facility Unavailable |
| Rest Of Louisiana | Office $94.91 | Facility Unavailable |
| Rest Of Maine | Office $96.51 | Facility Unavailable |
| Rest Of Maryland | Office $101.61 | Facility Unavailable |
| Rest Of Massachusetts | Office $103.88 | Facility Unavailable |
| Rest Of Michigan | Office $96.34 | Facility Unavailable |
| Rest Of Missouri | Office $93.80 | Facility Unavailable |
| Rest Of New Jersey | Office $107.11 | Facility Unavailable |
| Rest Of New York | Office $98.00 | Facility Unavailable |
| Rest Of Oregon | Office $100.24 | Facility Unavailable |
| Rest Of Pennsylvania | Office $96.52 | Facility Unavailable |
| Rest Of Texas | Office $98.02 | Facility Unavailable |
| Rest Of Washington | Office $103.71 | Facility Unavailable |
| Rhode Island | Office $103.09 | Facility Unavailable |
| Riverside-San Bernardino-Ontario | Office $106.09 | Facility Unavailable |
| Sacramento-Roseville-Folsom | Office $110.18 | Facility Unavailable |
| Salinas | Office $109.73 | Facility Unavailable |
| San Diego-Chula Vista-Carlsbad | Office $111.48 | Facility Unavailable |
| San Francisco-Oakland-Berkeley (Marin Cnty) | Office $125.24 | Facility Unavailable |
| San Francisco-Oakland-Berkeley (San Francisco/San Mateo/Alameda/Contra Costa Cnty) | Office $125.22 | Facility Unavailable |
| San Jose-Sunnyvale-Santa Clara (San Benito Cnty) | Office $127.59 | Facility Unavailable |
| San Jose-Sunnyvale-Santa Clara (Santa Clara Cnty) | Office $127.55 | Facility Unavailable |
| San Luis Obispo-Paso Robles | Office $108.03 | Facility Unavailable |
| Santa Cruz-Watsonville | Office $111.95 | Facility Unavailable |
| Santa Maria-Santa Barbara | Office $109.92 | Facility Unavailable |
| Santa Rosa-Petaluma | Office $113.04 | Facility Unavailable |
| Seattle (King Cnty) | Office $114.12 | Facility Unavailable |
| South Carolina | Office $96.78 | Facility Unavailable |
| South Dakota** | Office $100.31 | Facility Unavailable |
| Southern Maine | Office $99.97 | Facility Unavailable |
| Stockton | Office $105.94 | Facility Unavailable |
| Suburban Chicago | Office $102.47 | Facility Unavailable |
| Tennessee | Office $95.94 | Facility Unavailable |
| Utah | Office $97.58 | Facility Unavailable |
| Vallejo | Office $119.10 | Facility Unavailable |
| Vermont | Office $99.88 | Facility Unavailable |
| Virgin Islands | Office $101.07 | Facility Unavailable |
| Virginia | Office $99.61 | Facility Unavailable |
| Visalia | Office $105.94 | Facility Unavailable |
| West Virginia | Office $94.29 | Facility Unavailable |
| Wisconsin | Office $98.26 | Facility Unavailable |
| Wyoming** | Office $100.45 | Facility Unavailable |
| Yuba City | Office $105.94 | Facility Unavailable |
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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 indices and the applicable conversion factor. Unavailable or separately priced services are labeled rather than assigned a made-up amount.
Source: RVU26D. Effective 2026-10-01 through the day before 2027-01-01.
12,88097164,,Pt re-eval est plan care,A,,0.96,1.05,,1.05,NA,0.01,2.02,2.02,7,XXX,0.00,0.00,0.00,5,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
12,88197165,,Ot eval low complex 30 min,A,,1.54,1.46,,1.46,NA,0.01,3.01,3.01,7,XXX,0.00,0.00,0.00,5,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
12,88297166,,Ot eval mod complex 45 min,A,,1.54,1.46,,1.46,NA,0.01,3.01,3.01,7,XXX,0.00,0.00,0.00,5,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
12,88397167,,Ot eval high complex 60 min,A,,1.54,1.46,,1.46,NA,0.01,3.01,3.01,7,XXX,0.00,0.00,0.00,5,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
12,88497168,,Ot re-eval est plan care,A,,0.96,1.08,,1.08,NA,0.01,2.05,2.05,7,XXX,0.00,0.00,0.00,5,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
12,88597169,,Athletic trn eval low cmplx,N,,0.00,0.00,,0.00,,0.00,0.00,0.00,9,XXX,0.00,0.00,0.00,9,9,9,9,9,9,,33.4009,09,0,99,0.00,0.00,0.00
12,88697170,,Athletic trn eval mod cmplx,N,,0.00,0.00,,0.00,,0.00,0.00,0.00,9,XXX,0.00,0.00,0.00,9,9,9,9,9,9,,33.4009,09,0,99,0.00,0.00,0.00