97166 OT evaluation Medicare reimbursement rates in New York

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.