$96.56
Use 97166 when the occupational therapy evaluation supports moderate rather than low clinical decision-making complexity.
On this page
CMS RVU26D · Effective 2026-10-01
97165 OT evaluation Medicare reimbursement rates in New Mexico
Report 97165 for a low-complexity occupational therapy evaluation assessing functional performance and establishing or updating the patient’s therapy plan. Compare 97165 office and facility rates across CMS payment localities in New Mexico.
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 97165 in New Mexico?
New Mexico has 1 payment locality in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the payment area shown below, using the same CMS release.
Office / nonfacility
$96.56
1 of 1 localities have a supported rate.
Payment area: New Mexico
One mapped payment locality.
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.
Occupational therapy
About 97165: Low-complexity occupational therapy evaluation
Report 97165 for a low-complexity occupational therapy evaluation assessing functional performance and establishing or updating the patient’s therapy plan.
An occupational therapist evaluates how a patient performs daily activities, such as dressing, bathing, cooking, or using the hands for work and self-care. The therapist gathers a focused occupational profile and relevant medical or therapy history, identifies performance problems, and determines whether skilled occupational therapy is appropriate. Evaluations commonly take place in outpatient clinics, rehabilitation settings, or other locations where occupational therapy is provided.
Choose this level when the evaluation involves low-complexity clinical decision making, a limited number of performance deficits, and few needed modifications to the assessment. Document the profile and history reviewed, functional findings, clinical reasoning, and resulting plan of care. The code identifies an evaluation service, not a unit selected by elapsed treatment time. Medicare treats it as a therapy service rather than separate professional and technical claims. When multiple therapy services are furnished on the same day, practice expense is reduced for the second and later therapy units.
CMS billing rules for 97165
- 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%
185.8K
Medicare services in 2024 · #400 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.
97165 compared with similar codes
Office rates for New Mexico, from the same CMS release.
$96.56
Use 97167 for a high-complexity occupational therapy evaluation; 97165 represents the low-complexity level.
$65.54
Use 97168 for reevaluation of an established occupational therapy plan of care, rather than an initial low-complexity evaluation.
$94.11
97161 is a low-complexity physical therapy evaluation. Choose 97165 when the evaluated service is occupational therapy.
Compare 97165 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.
1 of 1 payment localities
New Mexico →
Office / nonfacility
$96.56
Facility
Unavailable
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How this local rate is calculated
Each RVU component is multiplied by its own geographic practice cost index (GPCI). The three adjusted components are added, then multiplied by the conversion factor. These are the inputs used for 97165 in New Mexico.
PPRRVU2026_Oct_nonQPP.csv
12,881
- Code
- 97165
- Physician work
- 1.54
- Practice expense
- 1.46
- Malpractice
- 0.01
GPCI2026.csv
77
- Locality
- New Mexico
- Physician work
- 1.000
- Practice expense
- 0.917
- Malpractice
- 1.201
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 1.54 | × 1.000 | 1.5400 |
| Practice expense | 1.46 | × 0.917 | 1.3388 |
| Malpractice | 0.01 | × 1.201 | 0.0120 |
| Total RVUs | 2.8908 | ||
| Conversion factor | × 33.4009 | ||
Office / nonfacility rate, New Mexico$96.56
Explore RVUs, geographic factors and the full formula
Office / nonfacility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 1.54 | 1 |
| Practice expense | 1.46 | 0.917 |
| Malpractice | 0.01 | 1.201 |
(1.54 × 1 + 1.46 × 0.917 + 0.01 × 1.201) × $33.4009 = $96.56
The office and facility calculations use their respective practice-expense RVUs. The facility amount here is the physician fee, not a separate hospital or facility bill.
97165 billing questions
How is 97165 different from 97166?
Use 97165 when the evaluation supports low-complexity decision making, limited performance deficits, and few assessment modifications. The moderate-complexity level, 97166, reflects greater evaluation complexity.
Is 97165 selected by the number of minutes spent?
No. Select the level from the evaluation’s complexity and documented findings; the code’s stated time is not a threshold for choosing 97165.
Can an occupational therapist bill treatment on the evaluation date too?
Distinct treatment services may be reported when separately furnished and documented. Medicare’s therapy multiple procedure payment reduction lowers practice expense for the second and later therapy units that day.
Should modifier 26 be appended to 97165?
No. Medicare treats 97165 as a therapy service, not as separate professional and technical components.
What documentation supports the low-complexity level?
Record the occupational profile and history reviewed, functional performance deficits found, clinical decision making, any assessment modifications, and the plan of care.
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.
12,87897162,,Pt eval mod complex 30 min,A,,1.54,1.38,,1.38,NA,0.01,2.93,2.93,7,XXX,0.00,0.00,0.00,5,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
12,87997163,,Pt eval high complex 45 min,A,,1.54,1.38,,1.38,NA,0.01,2.93,2.93,7,XXX,0.00,0.00,0.00,5,0,0,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
12,88097164,,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
7414312,NH,40,NEW HAMPSHIRE,1.000,1.041,0.875
7512402,NJ,01,NORTHERN NJ,1.063,1.160,1.068
7612402,NJ,99,REST OF NEW JERSEY,1.040,1.092,1.097
7704212,NM,05,NEW MEXICO,1.000,0.917,1.201
7813202,NY,01,MANHATTAN,1.064,1.162,1.586
7913202,NY,02,NYC SUBURBS/LONG ISLAND,1.064,1.189,1.857
8013202,NY,03,POUGHKPSIE/N NYC SUBURBS,1.045,1.095,1.210