OT evaluation codes 97165 to 97168

For owners of OT practices and their billing staff, serving children, adults or both: 97165, 97166 and 97167 report an OT evaluation of low, moderate or high complexity, judged on the occupational profile and history, the performance deficits found and the clinical decision making, and 97168 reports a re-evaluation. The service performed and documented sets the level, never time.⁠^1,2

What does each OT evaluation code from 97165 to 97168 cover?

97165, 97166 and 97167 report an initial occupational therapy evaluation at low, moderate and high complexity, and 97168 reports a re-evaluation of an established plan of care. They date from January 1, 2017, when the CPT Editorial Panel’s new set replaced the lone OT evaluation code, 97003, and the old re-evaluation code, 97004, and Medicare adopted the set.⁠¹ AOTA’s 2026 coding list files all four under OT evaluation and re-evaluation and points readers to the CPT codebook for how to select and document each level.⁠¹⁰

CPT is owned by the American Medical Association, a notice CMS prints in its own correct coding manual, so the summaries below are in plain words; when CMS adopted the codes it reminded therapists that the CPT manual’s evaluation subsections hold the official guidelines.⁠^1,5 Nothing here replaces the payer’s own policy or the current CPT and HCPCS code sets, which govern every claim; take a question about a particular claim to the payer or a certified coder, and read this guide as education.

Medicare lists all four as always-therapy codes that need the modifier of the discipline whose plan of care they serve, which for these codes is GO, and its claims manual says a discipline’s evaluation codes are always reported with that discipline’s modifier.⁠^3,4 The manual’s unit chart allows each of them once per provider, discipline, date and patient under an OT plan of care, and not at all under a PT or speech-language pathology plan.⁠⁴ The medically unlikely edit for each is 1 unit per date of service, set as a matter of CMS policy.⁠¹¹

Does the length of an OT evaluation decide which code to bill?

No. CMS said, when it adopted the codes, that the typical times in their descriptors are a frame of reference and not a minimum coding requirement, and that they describe the occupational therapist’s typical face-to-face time with the patient.⁠¹ AOTA’s coding overview goes further: time cannot be used as a factor in choosing the level, and one unit is billed however long the evaluation took.⁠² A 75-minute evaluation of a child with one targeted concern can still be a 97165, and a 40-minute evaluation of an adult whose record supports every high-complexity element can still be a 97167.

For Medicare, evaluation minutes are untimed. They count in the note’s total treatment time, they are never added to the timed-code minutes that set treatment units, and time spent evaluating cannot also be billed as treatment.⁠⁷ The eight-minute rule guide shows how the timed minutes on the same day turn into units.

Which three components set the level of an OT evaluation?

The occupational profile and history, the assessment that identifies performance deficits, and the clinical decision making set the level, each rated low, moderate or high.⁠^1,12 AOTA’s overview names those three as the factors that are scored, and treats the plan of care as part of every evaluation that must show how and why the evaluation was scored as it was.⁠²

AOTA’s rule for combining them is strict: to report a higher level, all three components must reach it. Its own example is a moderate profile and history, a moderate assessment and high decision making, which is still coded moderate.⁠² CMS, answering a commenter about evaluations that fall between two levels, pointed to the general coding principle: the therapist selects the level that best represents the service furnished and for which medical necessity is clearly documented.⁠¹ AOTA adds that the level is usually settled after the evaluation is complete, though knowing the criteria at the start lets the therapist gather what each component needs.⁠²

How deep should the occupational profile and history go?

As deep as the presenting problem requires: a brief history limited to the records about the presenting problem for low complexity, an expanded records review plus further physical, cognitive or psychosocial history tied to current function for moderate, and an extensive version of that review for high.⁠¹ AOTA’s overview warns against reading depth from the chart alone: a client with several diagnoses who is stable and wants one targeted issue addressed scores low on this component.⁠²

The profile itself has a defined content. AOTA’s template gathers it from the client’s own perspective, through formal and informal interview, and asks why the client is seeking services, in which occupations the client succeeds and what gets in the way, the client’s occupational history, values and interests, the contexts that help or hinder, daily routines and roles and how they have changed, and the client’s priorities and desired outcomes.⁠¹³ The same template states that the profile has been a requirement of the CPT OT evaluation codes since January 1, 2017, so an evaluation without one cannot support any of the three levels.⁠¹³ For a young child, record who supplied each answer, the parent, a teacher’s report or the child, since the template asks for the client’s own view.

How does an OT count performance deficits for the level?

By counting the occupations in which the client has problems that come from physical, cognitive or psychosocial skills: one to three for low complexity, three to five for moderate, and five or more for high.⁠^1,14 AOTA’s position is that a performance deficit should be read as an occupation in which the client is experiencing problems, documented in the plan of care, and that defining deficits means identifying the areas of occupation the plan of care is to address.⁠¹⁴ AOTA’s overview names the areas of occupation: activities of daily living and instrumental activities of daily living, education, work, play, leisure, rest and sleep, and social participation.⁠²

The skill categories explain why an occupation is limited. In the CPT introduction as AOTA reprints it, physical skills cover body structure or function such as balance, strength, coordination, sensation and dexterity; cognitive skills cover attending, problem solving, sequencing, learning and remembering so that a task is done safely and in good time; psychosocial skills cover interactions, habits, routines, coping and adaptations to the environment.⁠¹⁴

• Count each occupation once. A child who cannot button, zip or tie has one deficit, dressing, even though three tasks fail; the fine motor skill behind it is the reason, not a second deficit.⁠¹⁴
• Count only what the plan addresses. AOTA describes deciding with the client which deficits the episode takes on, so an occupation the client does not want to work on now is noted in the profile but not counted.⁠^2,14
• Read the overlap. The ranges share their end points, three and five, so a count of three or five does not settle the level by itself; AOTA says the count is only one factor, beside the profile, the history and the reasoning.⁠^1,14
• Measure where possible. AOTA’s overview prefers standardized assessments for identifying a deficit, then a decision with the client on whether it is addressed.⁠²

What moves OT clinical decision making from low to high?

Four markers move it: how broad the assessment data are, how many treatment options were weighed, whether comorbidities affect occupational performance, and how much the assessment had to be modified or assisted for the client to complete it. Low complexity analyzes problem-focused assessments, weighs a limited number of options, involves no comorbidity affecting performance and needs no modification or assistance; moderate analyzes detailed assessments, weighs several options, may involve comorbidities and needs minimal to moderate modification; high analyzes comprehensive assessments, weighs multiple options, involves comorbidities that affect performance and needs significant modification or assistance.⁠¹

AOTA’s overview gives examples for each marker. Hemiparesis may involve choosing among several options for treatment, adaptation or compensation, while a shoulder hemi-arthroplasty may be driven by a limited number; chronic obstructive pulmonary disease can affect breathing and fatigue during daily activities, and cognitive problems after a hospital stay are another common comorbidity; and modifying an assessment can mean changing its directions, task complexity, environment or time, which the note should record.⁠² Medicare’s manual asks for the same thing in its own terms: list the conditions and complexities and, where it is not obvious, describe how they affect the prognosis or the plan.⁠⁷

What does each OT evaluation level look like in the record?

Each component should leave its own trace in the evaluation, in terms a reviewer can line up with the level billed. The table sets the three levels side by side, component by component, with a sentence the note can carry.

The level is the one all three components reach, not the highest single row.⁠² When the rows split, write the reason the chosen level best represents the service, the test CMS set out.⁠¹

How does leveling an OT evaluation differ from leveling a PT one?

The OT codes count performance deficits in occupations across physical, cognitive and psychosocial skills, while the PT codes count personal factors and comorbidities in the history, elements examined across body structures and functions, activity limitations and participation restrictions, and rate the clinical presentation as stable, evolving or unstable.⁠¹ The typical times differ too: 20, 30 and 45 minutes for the PT levels against 30, 45 and 60 for the OT levels.⁠¹ When CMS proposed adopting the codes, the question it put to commenters about the OT family was how to define performance deficits and how an occupational therapist counts them.⁠¹

The billing rules run in parallel. GO goes on an OT evaluation and GP on a PT one, and Medicare’s unit chart allows the OT codes only under an OT plan of care.⁠⁴ NCCI bars one practitioner from reporting both an OT and a PT evaluation, while an OT and a PT who both evaluate the patient that day may each be reported.⁠⁵ The PT evaluation codes guide works through 97161 to 97164 the same way, for practices that offer both disciplines.

Does Medicare pay more for a high-complexity OT evaluation?

No. On CMS’s fee schedule look-up, updated October 1, 2026, the 2026 national payment amount at the non-QPP rate is $100.54 for 97165, for 97166 and for 97167 alike, in both the facility and non-facility columns, and $68.47 for 97168.⁠⁶ CMS chose equal values when it adopted the codes: in the 2017 rule it valued the three levels as a group, each at 1.2 work relative value units, saying this limits the incentives for and consequences of upcoding.⁠¹

That makes the level a record of complexity, not a lever on Medicare’s payment. AOTA’s overview reminds therapists that they are ethically, and in some cases legally, required to choose and report the correct code.⁠² What a Medicare patient pays for the evaluation in a given area, and how the deductible and coinsurance apply, are set out for families in the adult occupational therapy cost guide.

Do commercial and Medicaid plans pay the three levels differently?

Some may. CMS noted in 2017 that payers other than Medicare may have a direct interest in paying differently by complexity, and AOTA’s overview said the same about other payers.⁠^1,2 AOTA’s coding list adds that not every code is accepted by every payer.⁠¹⁰ For each plan, read its fee schedule entry for all four codes, ask whether the evaluation needs authorization and whether re-evaluations are limited, and keep the answer with the date. A plan that pays more for 97167 changes nothing about how the level is chosen: the components still decide.

When does Medicare cover a 97168 OT re-evaluation?

When the record shows a need for further tests and measurements after the initial evaluation. Medicare’s manual names the indications as new clinical findings, a significant change in the patient’s condition, or failure to respond to the interventions in the plan of care, and it says a formal re-evaluation is covered only if the documentation supports that need.⁠⁷ Its definitions frame the same test: a re-evaluation is indicated when the clinician’s assessment shows a significant improvement, decline or change in condition or function that the plan of care did not anticipate, and the decision to re-evaluate belongs to the clinician.⁠⁷

What does not qualify is just as specific. Continuous assessment of progress is part of ongoing therapy and is not payable as a re-evaluation, and a re-evaluation is not a routine, recurring service.⁠⁷ A state practice act may require re-evaluation at set intervals, but for Medicare payment the re-evaluation must also meet Medicare’s coverage guidelines.⁠⁷ One planned point does qualify: a re-evaluation may be appropriate before a planned discharge, to determine whether goals were met or to inform the physician or the next setting.⁠⁷

The code’s own components, summarized from the descriptor CMS published, are an assessment of changes in functional or medical status, an update to the occupational profile for changes in condition or environment, and a revised plan of care, with a formal re-evaluation tied to a documented change in function or a needed significant change to the plan.⁠¹ AOTA notes that CPT itself does not say when a re-evaluation may take place; payers do.⁠² On the claim, 97168 is one unit per date of service. NCCI says it should not be reported as a matter of routine during a planned course of therapy; if the patient’s status changes and the re-evaluation is reasonable and necessary, 59 or XU goes on 97168.⁠^5,11 Re-evaluation minutes are documented the same way as evaluation minutes.⁠⁷

Is a 90-day plan recertification a reason to bill 97168?

No. Recertification is the physician’s or nonphysician practitioner’s review and signature on the plan, while a re-evaluation is a clinical service the OT performs. The regulation requires recertification at least every 90 days, says the plan or other documentation must show the continuing need for occupational therapy, and requires the reviewing physician, nurse practitioner, clinical nurse specialist or physician assistant to sign.⁠⁸ The manual’s own timing is the earlier of two points: when a significant change to the plan becomes evident, or 90 days after treatment under the plan began.⁠⁷

The two events can meet: a covered re-evaluation that changes the plan significantly is a reason to send the revised plan for recertification. The reverse does not hold; a date on the calendar is not new clinical findings. Progress reports run on a third clock, at least once every 10 treatment days, and the manual says recertification dates do not affect when they are due.⁠⁷ What certification requires for patients, including its first 30-day window, is covered in the Medicare therapy coverage guide.

What should an OT evaluation note contain for Medicare?

The evaluation should show the need for a course of therapy through objective findings and the patient’s own report, with AOTA’s guidelines used as guidelines rather than as policy.⁠⁷ Only a clinician may perform an evaluation or re-evaluation; an OT may include an assistant’s objective measurements or observations made within the assistant’s scope, but must take an active, personal part and may not simply summarize what others found.⁠⁷ Medicare’s manual says occupational therapy assistants may not provide evaluative or assessment services.⁠⁷

The manual’s list of what an evaluation includes maps closely onto the three components:

• A diagnosis where state law allows a therapist to give one, or a description of the specific problem; Medicare’s own example is a physician’s diagnosis of stroke with hemiparesis as the OT’s treatment diagnosis.⁠⁷
• For OT and PT, the body part evaluated, and all the conditions and complexities that may affect treatment.⁠⁷
• Results from one of the four outcome instruments the manual names, recommended but not required, or in their place objective, measurable information on physical function, alongside the severity, prior care, quality of life and social support details the manual also lists.⁠⁷
• The clinician’s judgments about current function where they add to the measurement tools.⁠⁷
• Either a conclusion that no treatment is needed, or a prognosis, with its expected time frame, and a plan of care.⁠⁷

Medicare’s minimum for the plan of care is three items, the diagnoses, the long-term treatment goals, and the type, amount, duration and frequency of the services, and the plan has to agree with the evaluation.⁠⁷ When the evaluation is the only service in the episode, it serves as the plan of care if it contains a diagnosis, or, where a therapist may not diagnose, a description from which the referring physician can make one.⁠⁷

Which codes can an OT bill on the same day as an evaluation?

Most treatment codes, since Medicare’s manual lets evaluation and treatment be billed on one day or at later visits, but a few pairs are blocked.⁠⁷ Each edit names a column one code, which stays payable, and a column two code, which Medicare denies unless a proper modifier accompanies it; indicator 0 rules a modifier out, indicator 1 permits one when the circumstances justify it, and indicator 9 marks a pair deleted on the day it took effect.⁠^9,15 The rows are read from the practitioner file, version 323r0, effective October 1, 2026.⁠⁹

What the file does not contain matters as much. No live edit pairs 97530, 97110, 97112, 97140 or 97150 with 97165, 97166 or 97167: the file has no row at all for 97110 or 97112 with them, and the rows for 97530, 97140 and 97150 carry deletion dates equal to their effective dates. The rows pairing those five codes with 97168 ran from January 1, 2017 to December 31, 2019 and their later versions were deleted the day they took effect, October 1, 2020.⁠^9,15 So a child’s evaluation followed by 20 minutes of 97530 can carry both lines, as can an adult’s followed by 97535, which the file pairs only with 97168, provided the treatment minutes are separate from the evaluation minutes; NCCI’s manual says correct coding is expected whether or not an edit exists, and it allows no two therapy services in the same 15 minutes.⁠^5,7,9

Where an indicator 1 edit applies, the modifier must fit the facts. NCCI forbids adding a modifier only to get past an edit when the clinical facts do not justify it, and the documentation has to satisfy whatever the modifier requires.⁠¹⁵ The edit files change quarterly, so a pair cleared today needs checking again against each new quarter’s file.⁠⁹ The OT procedure codes guide covers the edits among the treatment codes themselves.

May an OT and a PT evaluate the same patient on one date?

Yes, when two different therapists do it. NCCI says an occupational therapist may report only one evaluation or re-evaluation on a date of service, that a single practitioner may not report both an OT and a PT evaluation, and that when two different practitioners perform the two evaluations on the same date both may be reported.⁠⁵ The same chapter lets two practitioners of different specialties report 97750, 97755 or 97763 beside the other’s evaluation with an NCCI-associated modifier, but not two practitioners of the same specialty.⁠⁵ Medicare’s unit rule is framed per provider, per discipline, per date and per patient.⁠⁴

How do pediatric OT practices level evaluations for children?

With the same three components and the same codes, applied to the occupations of childhood; the areas AOTA’s overview lists include play, education, rest and sleep, social participation and activities of daily living.⁠² AOTA keeps a separate FAQ on coding pediatric OT evaluations, noting that many occupational therapists, especially in pediatric settings, struggle with how to use these codes to report their evaluations accurately.⁠¹²

Three parts of a child’s evaluation need particular care in the record:

• The profile. The template asks for the client’s own perspective, so note what the child said or showed, and what came from a parent, a caregiver or a school report.⁠¹³
• The deficits. Count occupations, not test items: "dressing" and "handwriting for classwork" are two deficits, while low scores on three fine motor subtests behind them are evidence, not three more.⁠¹⁴
• The modifications. A child who needs directions changed, the task simplified, the room quieted or extra time, or physical or verbal help to finish a test, gives the decision-making component its evidence, and AOTA asks that each modification be documented.⁠^1,2

For a child enrolled in Medicaid, EPSDT applies: a state must provide diagnostic services when a screening shows a need for further evaluation, and any medically necessary service coverable under federal Medicaid law, even one the state plan does not list, and medical necessity is the state’s call, made child by child.⁠¹⁶ What the benefit requires of states, and what a pediatric practice records for it, are set out in the EPSDT guide. Read the state fee schedule or the managed care plan’s manual for how it pays the four codes and whether it limits re-evaluations. Watch one edit with a pediatric team: developmental testing codes 96112 and 96113 are column one over every OT evaluation code.⁠⁹ Evaluations that a school or an early intervention program carries out follow those programs’ own rules; how a private practice works alongside them is in the IEP guide and the infant development programs guide.

How do adult OT practices level evaluations under Medicare?

The same way, applied to an adult’s occupations, such as work, home management, medication routines, community participation and self-care, all within the areas of occupation AOTA’s overview lists.⁠² AOTA’s examples fit adult caseloads directly: hemiparesis may call for weighing several options for treatment, adaptation or compensation, and chronic lung disease or cognitive problems after a hospital stay are comorbidities that change how daily activities can be done.⁠² A comorbidity supports the level when the note shows how it affects the occupations evaluated, which Medicare’s manual asks for wherever the effect is not obvious.⁠^1,7

Medicare Part B adds the plan-of-care rules. The certification states that the patient needs the therapy, is under the care of a physician, nurse practitioner, clinical nurse specialist or physician assistant, and is treated under a plan of treatment, and the initial certification is obtained as soon as possible after the plan is established.⁠⁸ When a patient comes for an evaluation without a referral or order and needs no treatment, Medicare’s manual requires a physician’s referral, order or certification of the evaluation before it pays for the evaluation.⁠⁷ For a Medicare Advantage member, read the plan’s provider manual for its authorization steps and what it pays for each level before the first visit. Adults asking about a sensory evaluation are told what to expect in the adult sensory assessment guide, and the Medicare therapy coverage guide explains coverage from the patient’s side.

How might one child’s and one adult’s OT evaluations be leveled?

Component by component: rate the profile and history, the deficits and the decision making, take the level all three reach, then check the payer’s rules and the day’s edits. Both cases are invented to show the method, and each payer detail in them is an assumption for the example, not a description of a real plan.

Sources

1. Federal Register (Centers for Medicare & Medicaid Services). Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017 (final rule, 81 FR 80170, published November 15, 2016, effective January 1, 2017, document 2016-26668, Government Publishing Office text; section (56), evaluative procedures for physical therapy and occupational therapy, pages 80331 to 80338). Checked October 25, 2026.
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   “For CY 2017, the CPT Editorial Panel deleted four CPT codes (97001, 97002, 97003, and 97004) and created eight new CPT codes (97161-97168)”; “three new codes, also stratified by complexity, to replace a single code CPT code 97003, for occupational therapy (OT) evaluation, and one new code each to replace the re-evaluation codes for physical and occupational therapy, CPT codes 97002 and 97004.”; “we are finalizing our proposal to adopt new CPT codes 97161-97168 for PT and OT evaluations and re-evaluations.”; “For example, for the OT codes, we invited comment on how to define performance deficits, what process the occupational therapist uses to identify the number of these performance deficits that result in activity limitations, and performance factors needed for each complexity level.”; “are included as a frame of reference and do not represent a minimum coding requirement.”; “the typical times in the new PT and OT CPT codes represent the typical face-to-face time of the physical or occupational therapist with the patient.”; “the therapist should select the evaluation complexity level that best represents the furnished service and for which the medical necessity is clearly documented.”; “We would like to remind those requesting we assist in writing guidelines that the CPT manual PM&R subsections for PT and OT Evaluations contain official CPT guidelines.”; “we are finalizing our proposal to use the PAMA authority to value services as groups rather than individually--valuing each complexity level at 1.2 work RVUs for the PT and OT family of evaluation codes for CY 2017.”; “It limits the incentives for and consequences of upcoding by therapists and providers”; “other payers may have direct interest in making such differential payment based on complexity of OT and PT evaluation.”; “the re-evaluation requires a significant change in the patient’s condition or functional status that was not anticipated in the plan of care.”; “This means that they always represent therapy services regardless of who performs them and always require a therapy modifier, GP or GO, to signify that the services are furnished under a PT or OT plan of care, respectively.”. Table 23 of the rule reprints the CPT long descriptors, which belong to the American Medical Association, so they are summarized here in plain words, not quoted: for 97165, 97166 and 97167 in turn, an occupational profile with a medical and therapy history that is brief and limited to records about the presenting problem, or adds an expanded records review and further physical, cognitive or psychosocial history, or adds an extensive one; an assessment identifying one to three, three to five, or five or more performance deficits tied to physical, cognitive or psychosocial skills that cause activity limitations or participation restrictions; and clinical decision making of low, moderate or high complexity that analyzes the profile and data from problem-focused, detailed or comprehensive assessments and weighs a limited number, several or multiple treatment options, with no comorbidities, possible comorbidities, or comorbidities that affect occupational performance, and with no modification of tasks or assistance, minimal to moderate, or significant modification or assistance needed for the patient to complete the assessment; typical face-to-face times of 30, 45 and 60 minutes; for 97168, an assessment of changes in functional or medical status, an update to the occupational profile for changes in condition or environment, and a revised plan of care, with a formal re-evaluation tied to a documented change in function or a needed significant change to the plan, and a typical face-to-face time of 30 minutes; for the physical therapy codes 97161, 97162 and 97163, a history weighing personal factors and comorbidities, an examination counting elements across body structures and functions, activity limitations and participation restrictions, a clinical presentation that is stable, evolving or unstable, and typical face-to-face times of 20, 30 and 45 minutes.
2. American Occupational Therapy Association. New Occupational Therapy Evaluation Coding Overview (PDF, copyright 2016, linked as a resource from AOTA’s FAQs for coding pediatric OT evaluations page; line-break hyphens in the PDF are closed up here; its tables reprinting CPT descriptor language are not quoted). Checked October 25, 2026.
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   “These three factors must be “scored” and defensible documentation written to support the choice of a level.”; “The development of the Plan of Care (POC) is part of the overall evaluation process and must reflect how and why you scored the evaluation as high, moderate or low.”; “The level is most likely determined after completion of the evaluation, but therapists should be familiar with the criteria at the start so they can be considering the level as they proceed through the evaluation.”; “In order to move to a higher level of evaluation all three components must be of the higher level.”; “For example, if the profile and history are moderate and the assessment and identification of deficits in occupational performance is moderate, but the clinical decision making component is high, the evaluation must still be coded moderate.”; “they are ethically, and in some cases legally, required to choose and report the correct code.”; “Although a client may have multiple diagnoses, and be very complex, if he or she is in a stable state and wants one small or targeted issue addressed by the occupational therapy intervention, then this component should be coded as low complexity.”; “Ideally, the therapist will use standardized assessments to identify a performance deficit (activity limitation and/or participation restriction in occupations), and then decide with the client if that deficit is to be addressed.”; “OCCUPATIONS are various kinds of life activities in which individuals, groups, or populations engage, including activities of daily living, instrumental activities of daily living, rest and sleep, education, work, play, leisure, and social participation.”; “It is important to understand that the count of performance deficits or occupations in which the client is having difficulty is only one factor in assigning the level of the code.”; “For example, a secondary diagnosis of chronic obstructive pulmonary disease (COPD) may influence the client’s breathing and fatigue level, affecting completion of desired activities of daily living.”; “Another common comorbidity is problems in cognition; for instance, following an acute hospitalization.”; “When a client has difficulty with an assessment, the therapist may need to make modification of directions, task complexity, environment, time, or other factors.”; “Any modifications or adjustments in assessing performance deficits and activity limitations should be documented to show relationship to the level of evaluation code to choose.”; “For instance, treatment of hemiparesis may involve choosing among several options for treatment, adaptation, or compensatory activities.”; “But treatment of a shoulder hemi-arthroplasty may be driven primarily by a limited number of treatment options.”; “One unit of an evaluation code is submitted regardless of the amount of time spent on the evaluation; the complexity of the evaluation determines which level of code is selected.”; “Time Cannot Be Used as a Factor in Determining Levels.”; “CPT® does not speak to when a reevaluation can take place; those guidelines are usually provided by payers.”; “While at the time of this writing Medicare may pay the same for each level, other payers may determine different payment for each.”.
3. Centers for Medicare & Medicaid Services. Annual Therapy Update (page last modified March 4, 2026, with its 2026 Therapy Code List and Dispositions file; the workbook CY_2026_Therapy_Code_List_and_Dispositions_v3). Checked October 25, 2026.
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   “The files on this web page contain the list of codes indicating whether they are sometimes or always therapy services.”; disposition 5: “These codes are “always therapy” services, regardless of who performs them.”; disposition 9: “require a specific therapy modifier − GP, GO, or GN − to indicate when the evaluative service is furnished under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively.”; in the workbook, 97165, 97166, 97167 and 97168 each carry disposition 5 and disposition 9 with GO, effective January 1, 2017, with no term date.
4. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and CORF/OPT Services (Pub. 100-04, §§10.2, 20, 20.1 and 20.2). Checked October 25, 2026.
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   “Therapy modifiers are GP for physical therapy, GO for occupational therapy, and GN for speech-language pathology.”; “that discipline-specific evaluation and re-evaluation HCPCS codes are always reported with the modifier for the associated discipline (e.g. modifier GP with a HCPCS code for a physical therapy evaluation).”; “When reporting service units for HCPCS codes where the procedure is not defined by a specific timeframe (“untimed” HCPCS), the provider enters “1” in the field labeled units.”; “For any single timed CPT code in the same day measured in 15 minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes.”; “The codes that are allowed one unit for “Allowed Units” in the chart below may be billed no more than once per provider, per discipline, per date of service, per patient.”; “The codes allowed 0 units in the column for “Allowed Units”, may not be billed under a plan of care indicated by the discipline in that column.”; the §20.2 chart gives 97165, 97166, 97167 and 97168 one allowed unit under an occupational therapy plan of care and none under a physical therapy or speech-language pathology plan, and its consumer-friendly descriptions give the three OT evaluation levels typical times of 30, 45 and 60 minutes and the re-evaluation 30 minutes.
5. Centers for Medicare & Medicaid Services. NCCI Policy Manual for Medicare Services, Chapter XI, Medicine and Evaluation and Management Services (revision date January 1, 2026; sections A, P and V). Checked October 25, 2026.
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   “Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2025 American Medical Association. All rights reserved.”; “Providers/suppliers shall report the HCPCS/CPT code that describes the procedure performed to the greatest specificity possible.”; “An occupational therapist may report only one evaluation/re-evaluation (CPT codes 97165-97168) on a single date of service.”; “A physician or facility shall not report both an occupational therapy evaluation/re-evaluation service and physical therapy evaluation/re-evaluation service if performed by the same practitioner.”; “If the 2 services are performed by 2 different practitioners on the same date of service, both procedures may be reported.”; “With one exception, providers/suppliers shall not report more than one physical medicine and rehabilitation therapy service for the same fifteen-minute time period.”; “Physicians are expected to code correctly even in the absence of NCCI PTP edits.”; “The re-evaluation services shall not be routinely reported during a planned course of physical or occupational therapy.”; “However, if the patient’s status should change and a re-evaluation is medically reasonable and necessary, it may be reported with modifier 59 or XU appended to CPT code 97164 or 97168 as appropriate.”; “are not separately reportable for the same date of service with a physical therapy evaluation/re-evaluation CPT code (e.g., 97161-97164) or occupational therapy evaluation/re-evaluation CPT code (e.g., 97165-97168) when the 2 services are performed by a single practitioner or 2 practitioners of the same specialty.”; “If the 2 services are performed by 2 different practitioners of different specialties, the 2 services may be reported using an NCCI PTP-associated modifier.”; “occupational therapy evaluation (CPT codes 97165-97167) shall not be reported with more than one unit of service per episode of care.”; “occupational therapy re-evaluation (CPT code 97168) shall not be reported with more than one unit of service per date of service.”; the passage in section P.8 that bars these codes beside an evaluation names 97750, 97755 and 97763.
6. Centers for Medicare & Medicaid Services. Search the Physician Fee Schedule (PFS Look-up Tool, searched for year 2026, Non-QPP Rates, Pricing Information, the range 97165 to 97168, all modifiers, National Payment Amount; the tool reads “Data Updated: 10/01/2026”). Checked October 25, 2026.
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   “Use this search to view adjusted pricing amounts that reflect variations in pricing costs from area to area.”; for locality 0000000, the national payment amount: 97165, 97166 and 97167 each $100.54 non-facility and $100.54 facility; 97168 $68.47 non-facility and $68.47 facility; conversion factor 33.4009.
7. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220 definitions, §§220.1.2, 220.1.3, 220.3 and 230.2). Checked October 25, 2026.
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   “EVALUATION is a separately payable comprehensive service provided by a clinician, as defined above, that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities.”; “Evaluation is warranted e.g., for a new diagnosis or when a condition is treated in a new setting.”; “an outpatient therapy episode is defined as the period of time, in calendar days, from the first day the patient is under the care of the clinician (e.g., for evaluation or treatment) for the current condition(s) being treated by one therapy discipline (PT, or OT, or SLP) until the last date of service for that discipline in that setting.”; “Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, or decline, or change in the patient’s condition or functional status that was not anticipated in the plan of care.”; “Although some state regulations and state practice acts require re- evaluation at specific times, for Medicare payment, reevaluations must also meet Medicare coverage guidelines.”; “The decision to provide a reevaluation shall be made by a clinician.”; “The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits.”; “The plan of care shall contain, at minimum, the following information as required by regulation”; “Diagnoses;”; “Long term treatment goals; and”; “Type, amount, duration and frequency of therapy services.”; “The plan of care shall be consistent with the related evaluation, which may be attached and is considered incorporated into the plan.”; “Timely certification of the initial plan is met when physician/NPP certification of the plan is documented, by signature or verbal order, and dated in the 30 days following the first day of treatment (including evaluation).”; “Recertifications that document the need for continued or modified therapy should be signed whenever the need for a significant modification of the plan becomes evident, or at least every 90 days after initiation of treatment under that plan, unless they are delayed.”; “The initial evaluation, or the plan of care including an evaluation, should document the necessity for a course of therapy through objective findings and subjective patient self-reporting.”; “Utilize the guidelines of the American Physical Therapy Association, the American Occupational Therapy Association, or the American Speech-Language and Hearing Association as guidelines, and not as policy.”; “Only a clinician may perform an initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a plan of care.”; “A clinician may include, as part of the evaluation or re-evaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evaluation or re-evaluation.”; “The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.”; “Documentation of the evaluation should list the conditions and complexities and, where it is not obvious, describe the impact of the conditions and complexities on the prognosis and/or the plan for treatment such that it is clear to the contractor who may review the record that the services planned are appropriate for the individual.”; “A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated.”; “For example the medical diagnosis made by the physician is CVA; however, the treatment diagnosis or condition description for PT may be abnormality of gait, for OT, it may be hemiparesis, and for SLP, it may be dysphagia.”; “For PT and OT, be sure to include body part evaluated.”; “Include all conditions and complexities that may impact the treatment.”; “Results of one of the following four measurement instruments are recommended, but not required:”; “If results of one of the four instruments above is not recorded, the record shall contain instead the following information indicated by asterisks (*)”; “*Documentation required to indicate objective, measurable beneficiary physical function including, e.g.,”; “Clinician’s clinical judgments or subjective impressions that describe the current functional status of the condition being evaluated, when they provide further information to supplement measurement tools; and”; “A determination that treatment is not needed, or, if treatment is needed a prognosis for return to premorbid condition or maximum expected condition with expected time frame and a plan of care.”; “When an evaluation is the only service provided by a provider/supplier in an episode of treatment, the evaluation serves as the plan of care if it contains a diagnosis, or in states where a therapist may not diagnose, a description of the condition from which a diagnosis may be determined by the referring physician/NPP.”; “If the patient presented for evaluation without a referral or order and does not require treatment, a physician referral/order or certification of the evaluation is required for payment of the evaluation.”; “The time spent in evaluation shall not also be billed as treatment time.”; “Evaluation minutes are untimed and are part of the total treatment minutes, but minutes of evaluation shall not be included in the minutes for timed codes reported in the treatment notes.”; “Continuous assessment of the patient’s progress is a component of ongoing therapy services and is not payable as a re-evaluation.”; “A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services.”; “A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation.”; “Indications for a re-evaluation include new clinical findings, a significant change in the patient’s condition, or failure to respond to the therapeutic interventions outlined in the plan of care.”; “A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.”; “Reevaluation requires the same professional skills as evaluation.”; “The minutes for re-evaluation are documented in the same manner as the minutes for evaluation.”; “The minimum progress report period shall be at least once every 10 treatment days.”; “It should be emphasized that the dates for recertification of plans of care do not affect the dates for required progress reports.”; “OTAs may not provide evaluative or assessment services, make clinical judgments or decisions; develop, manage, or furnish skilled maintenance program services; or take responsibility for the service.”.
8. Code of Federal Regulations. 42 CFR 424.24, Requirements for medical and other health services furnished by providers under Medicare Part B (eCFR, read through the eCFR versioner for October 22, 2026, the date the title is up to date as of; paragraph (c), outpatient physical therapy, occupational therapy and speech-language pathology services). Checked October 25, 2026.
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   “The individual needs, or needed, physical therapy, occupational therapy, or speech-language pathology services.”; “The services were furnished while the individual was under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant.”; “The services were furnished under a plan of treatment that meets the requirements of § 410.61 of this chapter.”; “The initial certification must be obtained as soon as possible after the plan is established.”; “Recertification is required at least every 90 days.”; “When it is recertified, the plan or other documentation in the patient’s record must indicate the continuing need for physical therapy, occupational therapy or speech-language pathology services.”; “The physician, nurse practitioner, clinical nurse specialist, or physician assistant who reviews the plan must recertify the plan by signing the medical record.”; “the therapist has documented evidence that the plan of treatment has been delivered to the physician, NP, PA, or CNS within 30 days of completion of the initial evaluation, the certification does not need to be signed by a physician, NP, CNS, or PA who has knowledge of the case.”; “No references to an order or referral in this subsection shall be construed to require an order or referral for outpatient physical therapy, occupational therapy, or speech-language pathology services.”.
9. Centers for Medicare & Medicaid Services. Medicare NCCI Procedure to Procedure (PTP) Edits (page last modified September 1, 2026; 2026 Quarter 4 practitioner file, version 323r0, part 4 of 4, the part holding every column one code from 62292 on). Checked October 25, 2026.
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   “If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied unless a clinically appropriate NCCI PTP-associated modifier is also reported.”; “CMS posts changes to each of its NCCI PTP published edit files on a quarterly basis.”; “Practitioner PTP Edits v323r0 (612,539 Records) 62292/01912 -- U0003/U0004 - Effective Oct. 1, 2026; Posted September 2, 2026”. In that file (column one/column two, then the modifier indicator, where 0 is not allowed, 1 is allowed and 9 marks a pair whose deletion date equals its effective date), rows with no deletion date: each of 97165, 97166, 97167 and 97168 with 97750, 97755, 97763, 95851, 95852, 97151 and 97152, indicator 0; 97166/97165, 97167/97165 and 97167/97166, indicator 0; each of 97165, 97166 and 97167 with 97168, indicator 0; each of 97165 to 97168 with 96105, 96125, 96130, 96132, 96136, 96138 and 96146, indicator 1; 96112 and 96113 each with 97165, 97166, 97167 and 97168, indicator 1; 97129, 97130, 97533, 97535, 97537, 97542, 97760 and 97761 each with 97168, indicator 1; rows carrying deletion dates: 97530/97165, 97530/97166, 97530/97167, 97150/97165, 97150/97166 and 97150/97167, effective and deleted January 1, 2020, indicator 9; 97165, 97166 and 97167 each with 97140, effective and deleted January 1, 2020 and again October 1, 2020, indicator 9; 97110, 97112, 97140, 97150 and 97530 each with 97168, effective January 1, 2017 and deleted December 31, 2019, indicator 1, and again effective and deleted October 1, 2020, indicator 9; no row in the file pairs 97110, 97112 or 97535 with 97165, 97166 or 97167.
10. American Occupational Therapy Association. 2026 Frequently Used CPT and HCPCS Codes for Occupational Therapy (PDF coding list; code descriptors © 2026 American Medical Association). Checked October 25, 2026.
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    “Not all codes are accepted by all payers.”; “Codes listed are effective as of January 1, 2026.”; “Refer to the CPT® coding book for guidance on selecting and documenting the appropriate complexity level.”; the list places 97165, 97166, 97167 and 97168 under occupational therapy evaluation and re-evaluation.
11. Centers for Medicare & Medicaid Services. Medicare NCCI Medically Unlikely Edits (MUEs) (page last modified August 31, 2026, with the Practitioner Services MUE Table effective October 1, 2026). Checked October 25, 2026.
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    “An MUE is the maximum units of service (UOS) reported for a HCPCS/CPT code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service.”; the table gives 97165, 97166, 97167 and 97168 each a value of 1, with the adjudication indicator “2 Date of Service Edit: Policy”.
12. American Occupational Therapy Association. FAQs for coding pediatric OT evaluations (Coding and Billing Resources; the public summary, with the full resource open to AOTA members). Checked October 25, 2026.
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    “The OT evaluation CPT ® codes describe evaluation complexity of low, moderate, or high, based on criteria under three evaluation components, including the level of occupational/medical history, patient assessment, and clinical decision making.”; “Many occupational therapists, especially those in pediatric settings, struggle with how to best utilize these codes to accurately report their evaluation process.”; “This resource is designed to help occupational therapy practitioners in pediatric settings more accurately determine evaluation complexity for the OT evaluations they deliver.”.
13. American Occupational Therapy Association. AOTA Occupational Profile Template (PDF, copyright 2022). Checked October 25, 2026.
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    “The information is obtained from the client’s perspective through both formal and informal interview techniques and conversation.”; “Why is the client seeking services, and what are the client’s current concerns relative to engaging in occupations and in daily life activities?”; “In what occupations does the client feel successful, and what barriers are affecting their success in desired occupations?”; “What is the client’s occupational history (i.e., life experiences)?”; “What are the client’s values and interests?”; “What aspects of their contexts (environmental and personal factors) does the client see as supporting engagement in desired occupations, and what aspects are inhibiting engagement?”; “What are the client’s patterns of engagement in occupations, and how have they changed over time? What are the client’s daily life roles?”; “What are the client’s priorities and desired targeted outcomes”; “The occupational profile is a requirement of the CPT® occupational therapy evaluation codes as of January 1, 2017.”.
14. American Occupational Therapy Association. What are performance deficits in the OT evaluation CPT® codes? (Coding and Billing, dated October 7, 2021; the CPT introduction’s definitions of physical, cognitive and psychosocial skills that the page reprints are summarized, not quoted: physical skills as body structure or function such as balance, mobility, strength, endurance, motor coordination, sensation and dexterity; cognitive skills as attending, perceiving, problem solving, sequencing, learning and remembering so that performance is organized safely and in good time; psychosocial skills as interactions, habits, routines, coping and environmental adaptations that let a person take part in everyday tasks and social situations). Checked October 25, 2026.
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    “each of the three levels of evaluation complexity under the Assessment of Occupational Performance component requires a count of performance deficits.”; “Thus AOTA’s position is that performance deficits in the code language should be interpreted as occupations in which the client is experiencing problems and should be documented in the plan of care.”; “Defining deficits in the CPT® context is viewed as the process of identifying what areas of occupation(s) the plan of care will address.”; “The therapist should consider all information gathered in the history and occupational profile to determine with the client the priority of performance deficits to be included.”; “It is important to understand that the number of performance deficits (occupations in which the client is having difficulty) is only one factor in assigning the level of code.”.
15. Centers for Medicare & Medicaid Services. NCCI Policy Manual for Medicare Services, Chapter I, General Correct Coding Policies (revision date January 1, 2026; section E, Modifiers and Modifier Indicators). Checked October 25, 2026.
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    “A modifier shall not be appended to a HCPCS/CPT code solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use.”; “A CCMI of “0” indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit.”; “A CCMI of “1” indicates that NCCI PTP-associated modifiers may be used to bypass an edit under appropriate circumstances.”; “A CCMI of “9” indicates that the use of NCCI PTP-associated modifiers is not specified. This indicator is used for all code pairs that have a deletion date that is the same as the effective date.”; “Documentation in the medical record must satisfy the criteria required by any NCCI PTP-associated modifier used.”.
16. Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment (Centers for Medicare & Medicaid Services). Checked October 25, 2026.
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    “The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.”; “States are required to provide any additional 1905(a) services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan.”; “It is the responsibility of states to determine medical necessity on a case-by-case basis.”; “When a screening examination indicates the need for further evaluation of an individual’s health, diagnostic services must be provided.”.
17. DrSensory. DrSensory for therapists (the For Therapists hub). “DrSensory is a directory families use free to find occupational therapy, physical therapy and speech therapy clinics”; “The directory lists clinics rather than individual therapists, so one listing covers a whole practice at one address.”; “It does not mean DrSensory checked its clinical work.”. Checked October 25, 2026.
18. DrSensory. Therapy Clinic Directory Pricing. “We do not verify clinical quality.”; the comparison of free and claimed listings marks “A description in your own words” and “Ages and conditions treated” as part of a claimed listing only. Checked October 25, 2026.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. CPT belongs to the American Medical Association; the descriptions of 97165 to 97168 here are summaries in plain words, and the CPT codebook holds the official descriptors.