Low-complexity occupational therapy evaluation, typically 30 minutes face-to-face, for patients with no comorbidities affecting occupational performance and a limited set of treatment options.

Verified May 8, 2026 · 4 sources ↓

Medicare: $100.54
Total RVUs: 3.01
Global, days
Region: General

Drawn from CMS

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 4 cited references ↓

Occupational profile documenting patient's prior level of function, roles, and reason for referral
Medical and therapy history specific to the current presenting problem
Objective assessment findings covering one to three physical, cognitive, or psychosocial performance factors limiting activity or participation
Explicit statement that no comorbidities are present that affect occupational performance — this anchors the low-complexity designation
Clinical decision-making narrative showing a limited number of treatment options were considered
Plan of care with measurable, time-bound goals tied directly to assessed deficits
Total face-to-face time documented, reflecting the 30-minute benchmark
Therapist credentials and supervision level (OT vs. OTA with CO modifier if applicable)

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 52 Reduced services 59 Distinct service 76 Repeat, same physician 77 Repeat, another physician KX Documentation on file XS Separate structure

What this code covers

Source · Editorial summary grounded in 4 cited references ↓

CPT 97165 covers an initial OT evaluation classified as low complexity. The evaluation requires an occupational profile, a review of medical and therapy history relevant to the presenting problem, and assessment of one to three physical, cognitive, or psychosocial performance factors that restrict activity or participation. No comorbidities affecting occupational performance are present, clinical decision-making is limited in scope, and the evaluation components can be completed without task modification or physical/verbal assistance. Face-to-face time is typically 30 minutes.

This code replaced legacy code 97003 effective January 1, 2017, when CMS restructured OT initial evaluation codes into a tiered complexity system (97165–97167). It carries a global period of XXX, meaning no global period applies — each encounter is billed independently. The code appears frequently in orthopedic and hand surgery settings when OT is ordered post-operatively or following upper-extremity injury.

Complexity level is the key billing variable. If the patient presents with comorbidities that affect occupational performance or requires more than a limited number of treatment options, 97166 (moderate) or 97167 (high) is the appropriate code. Upcoding complexity without supporting documentation is a top audit trigger for this code family.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	1.54
Practice expense RVU	1.46
Malpractice RVU	0.01
Total RVU	3.01
Medicare national rate	$100.54
Global period	days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$100.54

Common denial reasons

The recurring reasons claims for CPT 97165 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Complexity level unsupported — documentation describes comorbidities or multiple treatment variables that align with 97166 or 97167 instead
Missing or vague plan of care; goals listed without measurable criteria or connection to assessment findings
Evaluation billed on same date as a treatment code without adequate documentation showing the evaluation was a distinct, separately identifiable service
Re-evaluation billed as initial evaluation — payers deny 97165 when records show a prior OT episode for the same condition
OTA performed the evaluation without the required CO modifier and supervising OT countersignature where required
Medical necessity not established — documentation lacks objective functional deficits or fails to connect deficits to a skilled OT need

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 4 cited references ↓

01When does 97165 cross into 97166 territory?

When the patient has comorbidities that affect occupational performance, or when clinical decision-making involves analyzing data from multiple sources with a broader range of treatment options. If your note describes any of those factors, bill 97166 — and document the comorbidities explicitly.

02Can 97165 be billed on the same day as a treatment code?

Yes, but the evaluation must be a distinct service from any treatment provided that day. Document the evaluation and treatment separately. Some payers require modifier 59 or XS to distinguish them on the same claim.

03Can an OTA perform and bill this evaluation?

No. Initial OT evaluations (97165–97167) must be performed by a licensed OT, not an OTA. If an OTA contributes to any part of the evaluation, the supervising OT must perform the skilled evaluation components and the documentation must reflect that clearly.

04Is 97165 subject to the therapy cap or KX modifier requirements under Medicare?

Yes. Medicare therapy cap thresholds apply to OT services including 97165. Once a patient's OT charges exceed the threshold in a calendar year, append modifier KX to certify that continued services are medically necessary and documentation supports that finding.

05How often can 97165 be billed for the same patient?

It can be billed again when a new episode of OT care begins or when a patient returns after a significant gap and requires a full re-evaluation. Billing it for a re-evaluation within an ongoing episode is a denial risk — use 97168 (OT re-evaluation) for that scenario.

06Does 97165 require a physician referral for Medicare billing?

Under Medicare, outpatient therapy including OT evaluations requires a referral or order from a physician or other qualified health professional. The referring provider's name and NPI must appear on the claim per CMS billing and coding article A56566.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures the occupational profile narrative, the specific performance factors assessed (physical, cognitive, or psychosocial), the absence of comorbidities affecting occupational performance, clinical decision-making rationale, and the documented plan of care with goal statements — all from therapist dictation. This prevents the most common denial: a complexity level that can't be defended because the note lacks an explicit statement on comorbidity status or records only one or two assessment components.

See how Mira captures CPT 97165 documentation