Re-evaluation of an occupational therapy established plan of care when a documented change in functional or medical status requires a revised care plan and updated occupational profile.

Verified May 8, 2026 · 7 sources ↓

Medicare: $68.47
Total RVUs: 2.05
Global, days
Region: General

Drawn from CMSAAPCPt-managementAshtGawendaseminars

Documentation requirements

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

Source · Editorial brief grounded in 7 cited references ↓

Documented change in functional or medical status that triggered the re-evaluation
Updated occupational profile reflecting changes in condition or environment affecting future interventions or goals
Explicit revised plan of care with updated goals and intervention strategies
Face-to-face time with patient and/or family documented in the note (typically 30 minutes)
Clear distinction from prior evaluation findings to support medical necessity of re-evaluation

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

59 Distinct service KX Documentation on file

What this code covers

Source · Editorial summary grounded in 7 cited references ↓

97168 is used when an OT identifies a documented change in a patient's functional or medical status that necessitates revising the existing plan of care. The service has three required components: an assessment of changes in functional or medical status, an update to the initial occupational profile reflecting how those changes affect future interventions or goals, and a revised plan of care. Typical face-to-face time is 30 minutes with the patient and/or family — but that's a benchmark, not a hard cap or floor.

This code is distinct from the initial OT evaluation codes (97165–97167), which cover plan-of-care development. 97168 applies only when a plan already exists and a significant enough change has occurred to warrant formal re-appraisal. Routine progress checks without a documented functional status change or plan revision do not support this code.

NCCI edits create hard stops between 97168 and several other therapy codes. 97168 is mutually exclusive with 97750, 97755, and 97763 — modifier 59 cannot bypass these edits. If you're also billing a same-day treatment code such as 97530, modifier 59 applies per the October 2020 NCCI reinstatement. Medicare and commercial payers may have additional frequency or medical-necessity criteria beyond what CPT guidelines require; verify payer-specific rules before submitting.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	0.96
Practice expense RVU	1.08
Malpractice RVU	0.01
Total RVU	2.05
Medicare national rate	$68.47
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	$68.47

Common denial reasons

The recurring reasons claims for CPT 97168 get rejected.

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

No documented change in functional status — routine progress note submitted instead of formal re-evaluation
Missing revised plan of care; note updated occupational profile but failed to document updated goals or interventions
Billed same-day as a mutually exclusive code (97750, 97755, or 97763) without recognizing that modifier 59 cannot override these edits
Payer frequency limitation exceeded — many Medicare contractors and commercial payers restrict how often 97168 can be billed per episode of care without prior authorization or additional documentation
Modifier GO missing when billing Medicare outpatient OT services, causing claim rejection

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01What separates 97168 from a standard progress note?

97168 requires all three components: documented change in functional or medical status, an updated occupational profile, and a formally revised plan of care. A progress note tracking expected improvement without a plan revision does not meet criteria.

02Can 97168 and 97530 be billed on the same date of service?

Yes, but modifier 59 must be appended to 97530 to indicate the therapeutic activity was a separate and distinct service from the re-evaluation. This applies under the NCCI edits reinstated October 1, 2020.

03Can 97168 be billed the same day as 97750, 97755, or 97763?

No. These code pairs are mutually exclusive under NCCI edits, and modifier 59 cannot override them. Do not bill 97168 with 97750, 97755, or 97763 on the same date of service.

04How often can 97168 be billed for Medicare patients?

CPT guidelines don't specify a frequency limit, but Medicare contractors and many commercial payers do. Some require prior authorization or additional documentation for re-evaluations beyond a set number per episode of care. Check your MAC's local coverage policies.

05Is modifier GO required when billing 97168 for Medicare?

Yes. When billing Medicare for outpatient OT services, modifier GO — indicating services delivered under an outpatient occupational therapy plan of care — is required on 97168 claims.

06Can a physician or PM&R specialist bill 97168, or is it OT-only?

The top billing specialties per CMS PUF data include occupational therapists, orthopedic surgery, and physical medicine and rehabilitation. Non-OT providers should verify their state scope of practice and payer credentialing requirements before billing this code.

07Does 97168 have a global period?

97168 carries a XXX global indicator, meaning the global period concept does not apply. Each re-evaluation stands alone and is not bundled into a surgical or procedural global package.

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 specific functional or medical status change that prompted the re-evaluation, documents the updates to the occupational profile, and records the revised plan of care with updated goals — the three required components CMS and payers look for. This prevents the most common denial: a note that reads like a progress note rather than a formal re-evaluation, which auditors flag immediately.

See how Mira captures CPT 97168 documentation