$64.58–$69.55
97164 is for physical therapy reevaluation of an established plan. Use 97168 for occupational therapy reevaluation.
On this page
CMS RVU26D · Effective 2026-10-01
97168 OT reevaluation Medicare reimbursement rates in Pennsylvania
Occupational therapists report 97168 when reassessing an established plan of care after functional or medical changes warrant renewed analysis and plan revision. Compare 97168 office and facility rates across CMS payment localities in Pennsylvania.
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 97168 in Pennsylvania?
Pennsylvania has 2 payment localities in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the 2 payment areas shown below, using the same CMS release.
Office / nonfacility
$65.50–$70.59
2 of 2 localities have a supported rate.
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 97168: Occupational therapy plan-of-care reevaluation
Occupational therapists report 97168 when reassessing an established plan of care after functional or medical changes warrant renewed analysis and plan revision.
An occupational therapist reassesses a patient who already has an established plan of care when a change in function or medical status calls for renewed clinical analysis. The therapist may review the patient’s occupational and medical history, assess current performance in daily activities, and determine whether goals or interventions need revision. This service is distinct from routine treatment progress and from an initial occupational therapy evaluation that establishes the plan.
Report one reevaluation when the reassessment supports a revised plan of care; document the change prompting reassessment, findings, clinical reasoning, and any updated goals or interventions. It is a therapy service, not a separately billed professional component, so a professional-component modifier does not apply. When multiple therapy units are furnished on the same day, CMS reduces the practice expense for the second and later units.
CMS billing rules for 97168
- 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 RVU0.96 · 47%
- Practice expense (office) RVU1.08 · 53%
- Malpractice RVU0.01 · 0%
41.1K
Medicare services in 2024 · #860 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.
97168 compared with similar codes
Office rates for Pennsylvania, from the same CMS release.
$96.52–$103.53
97165 is an initial OT evaluation at low complexity. Choose 97168 when an established plan is being reassessed after a change in status.
$96.52–$103.53
97167 is an initial OT evaluation at high complexity. Its complexity level does not make it a substitute for reevaluation of an established plan.
Compare 97168 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.
2 of 2 payment localities
Metropolitan Philadelphia →
Office / nonfacility
$70.59
Facility
Unavailable
Rest Of Pennsylvania →
Office / nonfacility
$65.50
Facility
Unavailable
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97168 billing questions
When should 97168 be chosen instead of an initial OT evaluation?
Use 97168 when the patient already has an established occupational therapy plan and a change in status prompts a reassessment and possible plan revision. Use an initial OT evaluation when establishing the plan of care.
How is 97168 different from physical therapy reevaluation 97164?
Both describe reevaluation of an established plan, but 97168 is for occupational therapy and 97164 is for physical therapy.
Can 97168 be reported with treatment on the same day?
A separately furnished therapy treatment may be reported when it is distinct from the reevaluation and supported by documentation. CMS reduces practice expense for the second and later therapy units furnished that day.
What documentation supports 97168?
Document the functional or medical change prompting reassessment, the therapist’s findings and analysis, and how the plan or goals were revised. Routine progress without a reevaluation and plan-of-care analysis does not support this service.
Does 97168 have a separate professional component?
No. It is a therapy service, and a professional-component modifier does not apply.
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.
12,88197165,,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
12,88597169,,Athletic trn eval low cmplx,N,,0.00,0.00,,0.00,,0.00,0.00,0.00,9,XXX,0.00,0.00,0.00,9,9,9,9,9,9,,33.4009,09,0,99,0.00,0.00,0.00
12,88697170,,Athletic trn eval mod cmplx,N,,0.00,0.00,,0.00,,0.00,0.00,0.00,9,XXX,0.00,0.00,0.00,9,9,9,9,9,9,,33.4009,09,0,99,0.00,0.00,0.00
12,88797171,,Athletic trn eval high cmplx,N,,0.00,0.00,,0.00,,0.00,0.00,0.00,9,XXX,0.00,0.00,0.00,9,9,9,9,9,9,,33.4009,09,0,99,0.00,0.00,0.00