Summary & Overview
CPT 97165: Occupational Therapy Evaluation, Low Complexity
CPT code 97165 is a nationally recognized billing code for low complexity occupational therapy evaluations. This code is used by providers to document and bill for assessments that involve a brief review of medical and therapy history, identification of 1-3 performance deficits, and clinical decision making of low complexity. The evaluation is typically performed in outpatient settings and involves direct interaction with the patient and/or family for about 30 minutes.
Major payers covering this code include Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare. The code is essential for tracking utilization and reimbursement trends in occupational therapy, as well as for understanding policy updates and clinical benchmarks. Readers will gain insight into the clinical context of occupational therapy evaluations, payer coverage, and the role of CPT 97165 in outpatient rehabilitation services. The publication also provides information on related codes, common modifiers, and associated diagnoses, offering a comprehensive overview for stakeholders in healthcare policy, billing, and clinical practice.
CPT Code Overview
CPT 97165 represents an occupational therapy evaluation of low complexity. This service involves developing an occupational profile and reviewing the patient's medical and therapy history, focusing on the presenting problem. The evaluation includes assessment of 1-3 performance deficits related to physical, cognitive, or psychosocial skills, which result in activity limitations or participation restrictions. Clinical decision making is of low complexity, with analysis of the occupational profile and problem-focused assessments, considering a limited number of treatment options. The patient presents with no comorbidities affecting occupational performance, and no modification of tasks or assistance is required to complete the evaluation. Typically, this service is delivered face-to-face with the patient and/or family for approximately 30 minutes. The most common site of service is outpatient therapy settings.
Clinical & Coding Specifications
Clinical Context
A patient presents to an outpatient occupational therapy clinic with mild functional limitations. The patient has no comorbidities affecting occupational performance. During the evaluation, the occupational therapist reviews the patient's medical and therapy history, focusing on the presenting problem. The therapist identifies 1-3 performance deficits related to physical, cognitive, or psychosocial skills, such as difficulty in walking or muscle weakness. The evaluation does not require modification of tasks or assistance for completion. Clinical decision-making is of low complexity, and the therapist spends approximately 30 minutes face-to-face with the patient and/or family. The goal is to assess activity limitations and participation restrictions to inform a plan of care.
Coding Specifications
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Modifiers:
Modifier Code Description GNServices delivered under an outpatient speech-language pathology plan of care GOServices delivered under an outpatient occupational therapy plan of care -
When to Use Modifiers:
- Use
GNwhen the occupational therapy evaluation is performed under a speech-language pathology plan of care. - Use
GOwhen the evaluation is performed under an occupational therapy plan of care.
- Use
-
Provider Taxonomies:
Taxonomy Name Specialty Occupational Therapist (Rehabilitative Services) Occupational therapy evaluation and treatment -
Typical Site of Service:
- Outpatient therapy settings.
Related Diagnoses
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R26.2- Difficulty in walking, not elsewhere classified- Relevant for patients presenting with mobility issues that may require occupational therapy evaluation.
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M62.81- Muscle weakness (generalized)- Indicates generalized muscle weakness, which can impact daily activities and is commonly assessed during occupational therapy evaluations.
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R29.6- Repeated falls- Used for patients with a history of falls, highlighting the need for functional assessment and intervention.
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G81.90- Hemiplegia, unspecified affecting unspecified side- Represents paralysis on one side of the body, often requiring occupational therapy to address activity limitations.
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I69.351- Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side- Indicates weakness or paralysis following a stroke, relevant for occupational therapy evaluation to determine functional deficits and plan interventions.
Related CPT Codes
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97166- Occupational therapy evaluation, moderate complexity- Used when the evaluation requires clinical decision-making of moderate complexity, typically 45 minutes face-to-face. This code is an alternative to
97165for patients with more complex needs.
- Used when the evaluation requires clinical decision-making of moderate complexity, typically 45 minutes face-to-face. This code is an alternative to
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97167- Occupational therapy evaluation, high complexity- Used for evaluations requiring high complexity clinical decision-making, typically 60 minutes face-to-face. This code is an alternative to
97165for patients with significant complexity.
- Used for evaluations requiring high complexity clinical decision-making, typically 60 minutes face-to-face. This code is an alternative to
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97168- Occupational therapy re-evaluation- Used when a re-evaluation is necessary to assess progress or modify the plan of care. This code is commonly used in follow-up visits after the initial evaluation with
97165.
- Used when a re-evaluation is necessary to assess progress or modify the plan of care. This code is commonly used in follow-up visits after the initial evaluation with
These codes are related to 97165 and are selected based on the complexity of the patient's condition and the evaluation required. 97166 and 97167 are alternatives for moderate and high complexity cases, while 97168 is used for subsequent re-evaluations.
National Reimbursement Benchmarks
Medicare's national mean rate for CPT code 97165 is $104.17, which is slightly higher than the BUCA (average commercial) mean rate of $101.92. Among the commercial payers, Cigna and UnitedHealth Group offer the highest mean rates at $119.81 and $114.01, respectively, while Aetna is the lowest at $96.08.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Medicare has the tightest range at $9.00, indicating relatively consistent reimbursement rates. In contrast, Cigna shows the widest dispersion at $67.38, reflecting greater variability in rates. Blue Cross Blue Shield and Aetna also display moderate ranges of $38.00 and $43.00, respectively.
The table and chart below present the full breakdown of national benchmarks for CPT code 97165 across major payers.
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