Billing code 97165: OT evaluationMedicare rate & RVUs in Oregon
Report 97165 for a low-complexity occupational therapy evaluation assessing functional performance and establishing or updating the patient’s therapy plan.
Medicare pays $100.24–$106.69 for 97165 in the office in Oregon, from Rest Of Oregon to Portland. 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 97165 covers
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.
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 97165 pays more and less in Oregon
| Payment locality | Office | Facility |
|---|---|---|
| Portland | $106.69 | Unavailable |
| Rest Of Oregon | $100.24 | Unavailable |
How the 97165 rate is calculated
Each of 97165’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 · 97165
RVUs × geographic indexes × conversion factor
Work1.54
1.54 RVUs× 1.000 GPCI
Practice expense1.46
1.46 RVUs× 1.000 GPCI
Malpractice0.01
0.01 RVUs× 1.000 GPCI
Adjusted RVUs
3.0100
Conversion factor
$33.4009
Medicare rate
$100.54
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 97165
The CMS indicators that decide how 97165 is paid alongside other services.
CMS payment indicators · 97165
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
97165 without CQ · national office
$100.54
OT evaluation
97165-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.
97165 compared with similar codes
Compare codes · National
5 codes, side by side
How to choose
- 97166OT evaluation
- Use 97166 when the occupational therapy evaluation supports moderate rather than low clinical decision-making complexity.
- 97167OT evaluation
- Use 97167 for a high-complexity occupational therapy evaluation; 97165 represents the low-complexity level.
- 97168OT reevaluation
- Use 97168 for reevaluation of an established occupational therapy plan of care, rather than an initial low-complexity evaluation.
- 97161PT evaluation
- 97161 is a low-complexity physical therapy evaluation. Choose 97165 when the evaluated service is occupational therapy.
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 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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