CPT 97165Physical Therapy

Ot eval low complex 30 min

CPT code 97165 is for a low complexity occupational therapy evaluation lasting 30 minutes. This is the initial assessment an occupational therapist performs when evaluating a patient with straightforward functional limitations.

Showing rates for

National Average

Base Medicare rate

$100.60

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

1.54

PE RVU (NF)

1.53

MP RVU

0.04

Total RVU

3.11

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Accurately select complexity level by documenting number of personal factors and comorbidities affecting occupational performance
Impact: Upcoding from 97165 to 97166 (moderate complexity, $132.10) without proper documentation is a common audit trigger; conversely, underutilizing 97166 when warranted costs $31.50 per evaluation
Ensure 30-minute minimum time threshold is met and documented in clinical notes with start/stop times
Impact: Time-based code audits are common; failure to document adequate time results in downcoding or denial of the $100.60 payment
Bill 97165 only once per episode of care; subsequent evaluations require re-evaluation codes (97167)
Impact: Billing multiple 97165 codes during same episode triggers automatic denials; use 97167 for re-evaluations to maintain compliant billing
Include required GO modifier for all Medicare OT claims to ensure proper plan of care tracking
Impact: Missing GO modifier results in automatic denial; resubmission delays payment by 30-45 days on average
Do not bill 97165 with treatment codes on the same day unless evaluation was unplanned and separately identifiable
Impact: Evaluation and treatment on same day typically bundles into treatment code; inappropriate billing creates audit exposure and requires refund of $100.60
Verify patient has not received an OT evaluation from another therapist in same group within past 30 days
Impact: Duplicate evaluations within short timeframe are frequently denied as not medically necessary unless change in condition is clearly documented

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Frequently asked questions

What is the difference between CPT 97165, 97166, and 97167?

97165 is a low complexity OT evaluation (30 min, $100.60), 97166 is moderate complexity (45 min, $132.10), and 97167 is high complexity (60 min, $163.60). Complexity is determined by number of personal factors/comorbidities (1-2 for low, 3+ for moderate, complex for high) and clinical decision-making required, not simply by time spent.

How often can you bill CPT code 97165?

Bill 97165 only once per episode of care or discipline. If the patient requires another evaluation during the same episode, you must use re-evaluation code 97168. A new evaluation (97165) is appropriate only when starting a completely new episode after discharge, or if there is a significant change requiring a new baseline assessment.

Can you bill 97165 and treatment codes on the same day?

Generally no. Most payers expect evaluation-only visits or treatment-only visits. If treatment is provided on evaluation day, it is typically bundled into the evaluation code. Exception: if an unplanned, separately identifiable treatment becomes medically necessary during evaluation, modifier 59 may allow separate billing with strong documentation.

What is the Medicare reimbursement for CPT 97165 in 2025?

The 2025 Medicare national average payment for CPT 97165 is $100.60 for both facility and non-facility settings. This is based on 3.11 total RVUs (1.54 work RVU, 1.53 PE RVU, 0.04 MP RVU) multiplied by the 2025 conversion factor of 32.3465. Actual rates vary by geographic locality.

Do you need a physician referral to bill 97165?

Yes, Medicare and most payers require a physician referral or order for occupational therapy evaluation services. The referral must include a diagnosis and specify OT evaluation. Some states allow direct access to OT without referral, but Medicare still requires certification of the plan of care by a physician.

What modifiers are required for CPT 97165?

For Medicare OT claims, modifier GO is required to identify services furnished under an occupational therapy plan of care. Telehealth services require modifier GT or 95. Other modifiers (59, 76) are used only in specific circumstances when services are distinct or repeated.

How long does a 97165 evaluation need to be?

CPT 97165 is a timed code requiring approximately 30 minutes of direct patient contact. While the descriptor states '30 min,' this represents typical time; actual documented time should support the service provided. Times significantly less than 30 minutes may not support code selection and could trigger downcoding during audit.