$95.94
Choose 97166 when the documented evaluation supports moderate rather than high complexity. Do not select between the levels based only on visit duration.
On this page
CMS RVU26D · Effective 2026-10-01
97167 OT evaluation Medicare reimbursement rates in Tennessee
Report this code for a high-complexity occupational therapy evaluation involving extensive assessment of occupational performance and complex clinical decision making. Compare 97167 office and facility rates across CMS payment localities in Tennessee.
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 97167 in Tennessee?
Tennessee 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
$95.94
1 of 1 localities have a supported rate.
Payment area: Tennessee
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 97167: High-complexity occupational therapy evaluation
Report this code for a high-complexity occupational therapy evaluation involving extensive assessment of occupational performance and complex clinical decision making.
An occupational therapist uses this evaluation to examine how a person’s health conditions affect daily activities, roles, and participation. It may involve a detailed occupational profile, review of relevant medical and therapy history, assessment of multiple areas of functional performance, and development of an individualized plan of care. Examples include evaluating a person after a stroke whose motor, cognitive, and self-care limitations interact with other clinical concerns. The CMS short descriptor identifies a 60-minute service, but complexity—not elapsed time alone—distinguishes this level.
Select the level from the documented occupational profile and history, performance deficits, assessment findings, and clinical decision-making demands. The record should support why the evaluation required high-complexity analysis and how findings informed the plan of care. Report one evaluation service rather than timed units. This is a therapy service, so a professional-component modifier does not apply. When multiple therapy units are billed for the same day, Medicare reduces practice expense for the second and later therapy units.
CMS billing rules for 97167
- 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%
26.8K
Medicare services in 2024 · #1017 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.
97167 compared with similar codes
Office rates for Tennessee, from the same CMS release.
$95.94
Choose 97165 for a low-complexity OT evaluation; 97167 requires documentation supporting high-complexity assessment and decision making.
$65.03
97168 is for reassessment of an established OT plan of care, while 97167 represents an initial OT evaluation.
$93.52
97163 is the high-complexity physical therapy evaluation. Use 97167 for an occupational therapy evaluation.
Compare 97167 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
Tennessee →
Office / nonfacility
$95.94
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 97167 in Tennessee.
PPRRVU2026_Oct_nonQPP.csv
12,883
- Code
- 97167
- Physician work
- 1.54
- Practice expense
- 1.46
- Malpractice
- 0.01
GPCI2026.csv
95
- Locality
- Tennessee
- Physician work
- 1.000
- Practice expense
- 0.909
- Malpractice
- 0.537
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 1.54 | × 1.000 | 1.5400 |
| Practice expense | 1.46 | × 0.909 | 1.3271 |
| Malpractice | 0.01 | × 0.537 | 0.0054 |
| Total RVUs | 2.8725 | ||
| Conversion factor | × 33.4009 | ||
Office / nonfacility rate, Tennessee$95.94
Explore RVUs, geographic factors and the full formula
Office / nonfacility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 1.54 | 1 |
| Practice expense | 1.46 | 0.909 |
| Malpractice | 0.01 | 0.537 |
(1.54 × 1 + 1.46 × 0.909 + 0.01 × 0.537) × $33.4009 = $95.94
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.
97167 billing questions
How is this code distinguished from the moderate-complexity OT evaluation?
Use this level when the documented profile, functional assessment, and clinical decision making support high complexity rather than moderate complexity. The 60-minute descriptor alone does not establish the level.
Is the evaluation billed in 15-minute units?
No. Report the evaluation as one service, not as timed units. The 60-minute figure is part of the CMS short descriptor.
Can a professional-component modifier be appended?
No. CMS identifies this as a therapy service for which the professional-component modifier does not apply.
What documentation supports high complexity?
Document the occupational profile and relevant history, assessed performance deficits, clinical findings, decision-making demands, and how the evaluation supports the plan of care.
What happens when other therapy units are billed on the same day?
Medicare reduces practice expense for the second and later therapy units billed that day. The reduction applies to therapy units, not by converting this evaluation into timed units.
When should an OT re-evaluation be reported instead?
Use the OT re-evaluation code when reassessing an established plan of care, rather than conducting an initial 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 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.
12,88097164,,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
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
9214412,RI,01,RHODE ISLAND,1.019,1.033,0.892
9311202,SC,01,SOUTH CAROLINA,1.000,0.924,0.850
9403402,SD,02,SOUTH DAKOTA**,1.000,1.000,0.336
9510312,TN,35,TENNESSEE,1.000,0.909,0.537
9604412,TX,31,AUSTIN,1.002,1.058,0.886
9704412,TX,20,BEAUMONT,1.000,0.910,0.929
9804412,TX,09,BRAZORIA,1.008,0.991,0.780