CPT 97167Physical Therapy

Ot eval high complex 60 min

CPT 97167 is the billing code for a high-complexity occupational therapy evaluation, typically lasting 60 minutes, when a patient has multiple medical conditions or complex functional limitations requiring extensive assessment.

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

Document all complexity factors explicitly: multiple comorbidities, psychosocial factors, cognitive deficits, multi-system involvement, or extensive environmental barriers. Medicare contractors require clear evidence distinguishing high complexity (97167) from moderate (97166) complexity.
Impact: Proper documentation supports $27.37 higher reimbursement compared to 97166 (moderate complexity) and prevents downcoding that could cost your practice thousands annually
Ensure the evaluation duration supports 60-minute typical time. While not strictly time-based, payers expect documentation consistent with the typical time frame. Brief evaluations completed in 20-30 minutes rarely meet high-complexity criteria.
Impact: Time-complexity mismatch is a top audit trigger; inadequate time documentation can result in downcoding to 97165 ($73.23) representing a $27.37 loss per claim
Always append modifier GO (or GP per payer) to indicate occupational therapy. This is required for proper adjudication and therapy cap tracking under Medicare.
Impact: Missing GO/GP modifier results in automatic denial or misapplication to wrong therapy discipline; requires resubmission and delays payment by 30-45 days
Bill only one evaluation code per discipline per episode of care. Subsequent re-evaluations should use 97168, not 97167, unless starting a completely new episode after discharge.
Impact: Duplicate evaluation billing triggers audits and potential recoupment; Medicare allows only one initial evaluation per condition per provider per episode
Document development of a comprehensive treatment plan including measurable functional goals, anticipated frequency/duration, and clinical reasoning for high complexity determination within the evaluation note.
Impact: Treatment plan is a required component; absence can justify denial or downcoding even with excellent assessment documentation, risking full $100.60 payment

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Frequently asked questions

What is the difference between CPT 97167 and 97166?

CPT 97167 is for high-complexity OT evaluations involving patients with multiple comorbidities, multi-system involvement, complex psychosocial factors, or significant cognitive deficits requiring extensive clinical analysis. CPT 97166 is moderate complexity for patients with less complicated presentations. The 2025 Medicare reimbursement difference is approximately $27 ($100.60 vs $73.23), making proper complexity determination financially significant.

How much does Medicare pay for CPT 97167 in 2025?

Medicare pays $100.60 for CPT 97167 in 2025 based on the national average non-facility rate. The facility rate is also $100.60. Actual payment may vary slightly based on geographic locality adjustments (GPCI). The code has 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.

Can occupational therapy assistants bill CPT 97167?

No. CPT 97167 is an evaluation code that must be performed by a licensed occupational therapist (OTR/L). Occupational therapy assistants (OTA/COTA) cannot independently perform or bill for evaluations under Medicare rules and most state practice acts. OTAs can provide treatment services under OTR supervision but all evaluation and re-evaluation codes (97165-97168) require the licensed therapist.

What modifier is required for CPT 97167?

Modifier GO is required for Medicare claims to identify the service as occupational therapy. Some payers accept GP instead. Without the appropriate therapy discipline modifier, claims will deny or process incorrectly. Additional modifiers like 59 (distinct service) or GT (telehealth) may be appropriate depending on circumstances, but GO/GP is mandatory for OT identification.

How many times can you bill CPT 97167 for the same patient?

Medicare allows one initial evaluation (97167, 97166, or 97165) per occupational therapy episode of care. You cannot bill another initial evaluation until the patient is formally discharged and later returns for a new episode with a new condition or significant change. During ongoing treatment, use 97168 for re-evaluations. Billing multiple 97167 codes in the same episode triggers denials for duplicate services.

What documentation is needed to support high complexity for 97167?

Documentation must explicitly demonstrate high complexity through multiple comorbidities (3+ conditions affecting function), multi-system involvement, significant cognitive/perceptual deficits, complex psychosocial factors, or extensive environmental barriers. The evaluation should assess 5+ functional domains, include standardized assessments, demonstrate advanced clinical reasoning, and develop a comprehensive treatment plan. Simply spending 60 minutes is insufficient; complexity of clinical presentation and decision-making determines code selection.

Can CPT 97167 be billed on the same day as treatment codes?

Yes, but it's uncommon in outpatient settings. When billing 97167 with treatment codes (97110, 97530, etc.) on the same day, ensure clear documentation of both the evaluation and separate treatment session. Some payers may require modifier 59 to indicate distinct services. Medicare allows this but scrutinizes same-day evaluation and treatment for medical necessity. Most practices schedule evaluation-only visits to allow adequate time for comprehensive assessment.