CPT 97165: Occupational Therapy Evaluation, Low Complexity
Medicare pays $104 and commercial payers pay $173 on average nationally for this procedure.
CPT code 97165 describes an occupational therapy evaluation of low complexity performed by an occupational therapist that includes an occupational profile, focused assessment data, and consideration of a limited number of treatment options; the service typically requires 30 minutes of face-to-face time with the patient and/or family and is provided in outpatient, clinic, or other ambulatory therapy settings where no health issues affecting occupational performance are present.
For related coverage guidance, see recent payer policy updates: Home Health, Skilled, and Custodial Care Services (for Idaho Only), Private Duty Nursing Services, Private Duty Nursing Services (for Florida Only).
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National Reimbursement Benchmarks
Average commercial reimbursement for CPT 97165 at BUCA is notably higher than Medicare: BUCA’s mean is $173.50 versus Medicare’s mean of $104.20, a gap of $69.30. That difference places commercial rates substantially above the national Medicare average, with BUCA centered well above Medicare’s interquartile midpoint ($102) and upper quartile ($107).
Dispersion varies across payers: Blue Cross Blue Shield shows the widest interquartile spread (P75–P25 = $167.00), indicating greater variability in upper-range commercial contracts, while Aetna and Cigna exhibit tighter IQRs (Aetna = $67.00, Cigna = $43.00). UnitedHealth Group’s IQR is $40.00 and BUCA’s IQR is $96.00. Medicare’s IQR is narrow at $9.00, reflecting relatively consistent local payment levels.