Occupational therapy initial evaluation at high complexity, involving extensive history review, assessment of five or more performance deficits, and high-analytic-complexity clinical decision-making — typically 60 minutes face-to-face.

Verified May 8, 2026 · 6 sources ↓

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

Drawn from CMSAotaAAPCTheraplatform

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Occupational profile with extensive review of medical and therapy records, including history related to current functional performance
Standardized or non-standardized assessments identifying five or more physical, cognitive, or psychosocial performance deficits
Documentation of comorbidities and their specific impact on occupational performance
High-analytic-complexity clinical decision-making narrative — analysis of patient profile, assessment data synthesis, and rationale for multiple treatment options considered
Plan of care developed from evaluation findings, including goals and proposed interventions
Physician or NPP referral/order on file prior to or certifying the evaluation
Face-to-face time documented when time is used to support complexity level; 60 minutes is the typical benchmark

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 KX Documentation on file

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

97167 is the highest-complexity tier in the OT initial evaluation family (97165–97167). It requires an extensive occupational profile, a thorough review of medical and therapy records, and evaluation of five or more physical, cognitive, or psychosocial performance deficits that limit activity or restrict participation. The patient typically presents with comorbidities affecting occupational performance, and task completion requires significant modification or assistance. The OT must document high-analytic-complexity clinical decision-making — analyzing the full patient profile, synthesizing comprehensive assessment data, and weighing multiple treatment options.

The 60-minute face-to-face time is the typical benchmark, not a hard threshold. The complexity of the assessment drives code selection, not the clock alone. 97167 must be billed by the occupational therapist, not an OTA — if an OTA performs any portion, CQ modifier rules apply per CMS guidance. A physician referral or order is required for Medicare payment; an order dated after the evaluation is accepted as certification under CMS policy.

97167 carries a XXX global period, meaning standard surgical global rules don't apply. It is billed in outpatient and private practice settings — no HOPD or ASC facility payment rates exist for this code. Top billing specialties include occupational therapists in private practice and orthopedic surgery practices with integrated therapy services.

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 97167 get rejected.

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

Fewer than five performance deficits documented — drops the claim to 97165 or 97166 level on audit
OTA performed the evaluation without CQ modifier appended, triggering a Medicare compliance flag
Missing physician referral or order — required for Medicare payment of any OT evaluation
Insufficient clinical decision-making narrative; summarizing others' objective findings rather than independent assessment and reasoning
Upcoding from 97166 without documentation supporting high-complexity criteria — comorbidity impact and multiple treatment options must be explicit

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01What separates 97167 from 97166?

97166 (moderate complexity) requires two to four performance deficits and moderate clinical decision-making. 97167 requires five or more deficits, comorbidities affecting occupational performance, and high-analytic-complexity decision-making with multiple treatment options considered. Count your documented deficits before selecting the code.

02Can an OTA bill 97167?

No. Initial OT evaluations must be performed by the occupational therapist. If an OTA contributes any portion of the service, append the CQ modifier per CMS billing guidance — but the OT must perform and document the evaluation itself.

03Is 60 minutes a hard requirement to bill 97167?

No. Sixty minutes is the typical face-to-face time, not a mandatory threshold. Complexity criteria — five or more deficits, comorbidities, high-analytic decision-making — drive code selection. That said, document actual time, because auditors use it as a proxy for complexity.

04Can 97167 and 97168 be billed on the same date?

No. 97167 is an initial evaluation that includes development of a plan of care. 97168 is a re-evaluation for patients already on an established plan. They are mutually exclusive by definition — use 97167 for new patients or new episodes of care.

05What modifier is needed when medical necessity for high complexity is borderline and a Medicare claim may face scrutiny?

Append modifier KX when you are attesting that the documentation in the medical record supports the medical necessity criteria for the billed service. For 97167, this means the record must explicitly support all high-complexity elements before KX is applied.

06Is 97167 billable in a hospital outpatient department (HOPD)?

There is no separate HOPD or ASC facility payment rate for 97167. The code is billed under the Physician Fee Schedule in outpatient and private practice settings. Confirm payer-specific coverage in institutional settings before billing.

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, names each performance deficit identified (physical, cognitive, or psychosocial), documents comorbidities with explicit functional impact language, and records the OT's clinical reasoning and treatment options considered. That documentation prevents downcoding to 97166 on audit by ensuring all five deficit categories are named and the high-complexity decision-making rationale is explicit — not just implied.

See how Mira captures CPT 97167 documentation