Summary & Overview
CPT 97167: Occupational Therapy Evaluation, High Complexity
CPT 97167 denotes a high-complexity occupational therapy evaluation used to assess patients with significant functional deficits and to develop a comprehensive, skilled intervention plan. Nationwide, this code is important for capturing the intensity of clinical assessment and the corresponding level of occupational therapy expertise required. It is commonly applied when multiple performance limitations or comorbidities require extensive evaluation and clinical decision-making.
The analysis covers major national payers including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare. Readers will find a concise overview of payer coverage patterns, coding relationships to adjacent occupational therapy evaluation codes, and the clinical contexts that typically justify high-complexity evaluations. The content outlines how CPT 97167 fits within the spectrum of occupational therapy evaluation codes and highlights common clinical diagnoses and service settings associated with use.
This publication provides operationally focused information: definitions and clinical context for the code, links to related procedure codes used for comparison, and common administrative considerations such as typical site of service. Data not available in the input is noted where applicable.
CPT Code Overview
CPT 97167 is an Occupational Therapy evaluation of high complexity that documents a comprehensive assessment of a patient’s functional abilities, needs, and therapy goals. The service focuses on detailed evaluation of occupational performance, including assessment of multiple performance deficits and extensive clinical decision-making to establish a skilled treatment plan.
Service Type: Occupational Therapy
Typical Site of Service: Office (POS 11)
Clinical & Coding Specifications
Clinical Context
A 68-year-old patient presents to an outpatient occupational therapy clinic (Office, POS 11) 4 weeks after an ischemic stroke with residual right-sided hemiparesis and generalized muscle weakness. The occupational therapist conducts a comprehensive, high-complexity evaluation to assess functional status, cognitive interaction with tasks, sensory and motor deficits, and home-related safety needs. The visit includes history review, extensive standardized and therapy-specific assessments, development of an individualized plan of care, and documentation of measurable functional deficits and planned interventions. The typical clinical workflow includes referral review, patient interview and history, performance-based assessments, treatment planning, and coordination with the interdisciplinary team.
Coding Specifications
Modifier 59 - Distinct Procedural Service
- Used when the occupational therapy evaluation is separate and distinct from other services provided on the same day and meets payer policies for a distinct procedural service.
Modifier 76 - Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
- Used when the same occupational therapist repeats the high-complexity evaluation on the same date of service for the same patient due to medical necessity.
Associated Provider Taxonomies
| Taxonomy Code | Specialty Name |
|---|---|
225X00000X | Occupational Therapist |
225XE0001X | Environmental Modification Occupational Therapist |
225XF0002X | Feeding, Eating & Swallowing Occupational Therapist |
- Occupational Therapist (
225X00000X): Provides comprehensive OT evaluations and treatment. - Environmental Modification Occupational Therapist (
225XE0001X): Focuses on home and community environment adaptations identified during high-complexity evaluations. - Feeding, Eating & Swallowing Occupational Therapist (
225XF0002X): Addresses dysphagia and feeding-related functional deficits that may be identified during evaluation.
Related Diagnoses
-
R26.2— Difficulty in walking, not elsewhere classified- Clinically relevant as a functional mobility deficit evaluated during
97167, informing gait, transfers, and tolerance assessments.
- Clinically relevant as a functional mobility deficit evaluated during
-
M62.81— Muscle weakness (generalized)- Clinically relevant as a primary impairment affecting functional performance, strength testing, and intervention planning during the high-complexity evaluation.
-
G81.90— Hemiplegia, unspecified affecting unspecified side- Clinically relevant as a neurologic motor deficit assessed during
97167to determine task-specific limitations and adaptive needs.
- Clinically relevant as a neurologic motor deficit assessed during
-
I69.351— Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side- Clinically relevant as a post-stroke condition driving the need for a high-complexity occupational therapy evaluation to address dominant-side functional loss and activities of daily living.
-
Z47.89— Encounter for other orthopedic aftercare- Clinically relevant when orthopedic aftercare contributes to functional limitations assessed in the high-complexity evaluation and when coordination of ongoing aftercare is required.
Related CPT Codes
| CPT Code | Description | Clinical Relationship |
|---|---|---|
97165 | Occupational therapy evaluation, low complexity | Alternative for patients with simpler problems and lower assessment complexity compared to 97167. Often selected when fewer deficits and limited decision-making are present. |
97166 | Occupational therapy evaluation, moderate complexity | Alternative for intermediate complexity evaluations; used when assessment and clinical decision-making are between low and high complexity. |
97168 | Occupational therapy re-evaluation | Used for subsequent evaluations to document change or adjust the plan of care after the initial high-complexity evaluation 97167. Commonly used following 97167 when progress or regression is assessed. |
97530 | Therapeutic activities, direct (one-on-one) patient contact | Treatment code used in follow-up therapy sessions after the evaluation 97167 to address functional deficits through therapeutic activities. Frequently billed in the plan of care initiated by a high-complexity evaluation. |
- Codes
97165,97166, and97167are alternative initial evaluation levels selected based on complexity. 97168is functionally related as the re-evaluation after an initial97167.97530is commonly used together with97167as the active treatment modality in subsequent visits.
National Reimbursement Benchmarks
Medicare's mean allowed amount for CPT 97167 is $104.17, which sits slightly above the BUCA (average commercial) mean of $100.02. This places Medicare marginally higher than the aggregate commercial benchmark while remaining below the highest commercial payer mean, which is Cigna at $120.05.
Rate dispersion (75th minus 25th percentile) varies across payers. Cigna shows the widest spread at $68.00 (142 - 74), indicating the largest variability in allowed amounts. BCBS and BUCA have moderate dispersion at $37.00 and $37.08 respectively. Aetna is relatively tight with a spread of $31.00, UnitedHealth Group (UHC) shows a spread of $32.50, and Medicare is the tightest among these payers with a spread of $9.00. The table and chart below present the full breakdown.
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