CPT 97166: Occupational Therapy Evaluation, Moderate Complexity
Medicare pays $104 and commercial payers pay $177 on average nationally for this procedure.
CPT code 97166 describes an occupational therapy evaluation of moderate analytic complexity, involving an occupational profile, expanded medical/therapy history, and assessment of three to five physical, cognitive, or psychosocial performance factors to identify limitations in activity or participation; the service type is occupational therapy evaluation and the typical site of service is outpatient clinic or office-based therapy with approximately 45 minutes of face-to-face time with the patient and/or family.
For related coverage guidance, see recent payer policy updates: Home Health, Skilled, and Custodial Care Services (for Idaho Only), Private Duty Nursing Services (for Florida Only), Private Duty Nursing Services.
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National Reimbursement Benchmarks
Medicare’s mean rate sits at $104.20, which is modestly lower than BUCA’s average commercial mean of $176.70, indicating that commercial BUCA reimbursements are roughly $72.50 higher on average than traditional Medicare for CPT 97166. This gap highlights a persistent premium in commercial contracting relative to Medicare baseline reimbursement for this evaluation code.
Dispersion varies across payers: Blue Cross Blue Shield shows the widest interquartile spread with a P75–P25 range of $177.60 ($302.10 − $132.50), signaling substantial variability in commercial arrangements. Aetna has a narrower IQR of $49.00 ($115.00 − $64.00), and Cigna’s IQR is $44.00 ($119.20 − $76.00). UnitedHealth Group’s IQR is $39.40 ($118.20 − $78.80), while BUCA’s IQR is $115.00 ($223.00 − $107.00). Overall, Blue Cross Blue Shield is the most dispersed and UnitedHealth Group among the tightest.