Billing code 97167: OT evaluationMedicare rate & RVUs in Illinois
Report this code for a high-complexity occupational therapy evaluation involving extensive assessment of occupational performance and complex clinical decision making.
Medicare pays $96.48–$102.47 for 97167 in the office in Illinois, from Rest Of Illinois to Suburban Chicago. 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.
On this page 9 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.
Where 97167 pays more and less in Illinois
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
4 payment localities
$96.48 to $102.47
| Payment locality | Office | Facility |
|---|---|---|
| Chicago | $101.57 | Unavailable |
| East St. Louis | $96.97 | Unavailable |
| Rest Of Illinois | $96.48 | Unavailable |
| Suburban Chicago | $102.47 | Unavailable |
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
Swap in your local Medicare rate.
Work 1.54Practice expense 1.46Malpractice 0.01
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 97167
The CMS indicators that decide how 97167 is paid alongside other services.
CMS payment indicators · 97167
OT evaluation
| 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
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.
97167 compared with similar codes
Compare codes
97167 vs 97166 vs 97165 vs 97168 vs 97163: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 97166OT evaluation
- Choose 97166 when the documented evaluation supports moderate rather than high complexity. Do not select between the levels based only on visit duration.
- 97165OT evaluation
- Choose 97165 for a low-complexity OT evaluation; 97167 requires documentation supporting high-complexity assessment and decision making.
- 97168OT reevaluation
- 97168 is for reassessment of an established OT plan of care, while 97167 represents an initial OT evaluation.
- 97163PT evaluation
- 97163 is the high-complexity physical therapy evaluation. Use 97167 for an occupational therapy evaluation.
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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