Billing code 97166: OT evaluationMedicare rate & RVUs in Kansas
Report this occupational therapy evaluation when a moderate-complexity assessment of functional performance, relevant history, and treatment needs supports a plan of care.
Medicare pays $95.69 for 97166 in the office in Kansas (Kansas). 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 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.
97166 in Kansas
| Payment locality | Office | Facility |
|---|---|---|
| Kansas | $95.69 | Unavailable |
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.
How the rate is built · 97166
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 97166
The CMS indicators that decide how 97166 is paid alongside other services.
CMS payment indicators · 97166
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
97166 without CQ · national office
$100.54
OT evaluation
97166-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.
97166 compared with similar codes
Compare codes
97166 vs 97165 vs 97167 vs 97168: national Medicare rates
Swap in your local Medicare rate.
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.
97166 billing questions
How is 97166 different from 97165?
97166 is for moderate-complexity evaluation, generally supported by 3–5 performance deficits and moderate analytic decision-making. 97165 is the low-complexity level.
When should 97167 be used instead?
Use 97167 when the evaluation supports high rather than moderate complexity, based on the profile and history, performance deficits, clinical decision-making, and assistance or task modification documented.
Is 97166 billed as a timed service?
Report one evaluation, not units for each 15-minute interval. The 45-minute descriptor reflects the typical evaluation time.
Can modifier 26 be appended?
No. CMS identifies 97166 as a therapy service for which the professional-component modifier does not apply.
What documentation supports moderate complexity?
Document the expanded occupational profile and relevant history, functional performance deficits, clinical decision-making, and any comorbidities or assistance and task modifications that affected the 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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