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CPT 97167: Occupational Therapy Evaluation, High Analytic Complexity
CPT code 97167 represents a high complexity occupational therapy evaluation that supports clinical decision‑making for patients whose health issues substantially affect occupational performance. The evaluation includes an occupational profile, in‑depth review of medical and therapy history related to the presenting problem, and assessment of five or more physical, cognitive, or psychosocial performance factors. Typical face‑to‑face time is about 60 minutes. Nationally, this code matters because it captures resource intensity, care planning complexity, and justification for therapy services in diverse care settings.
Key payers covered in the review include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find clinical and billing context for using 97167, comparisons with related occupational therapy evaluation codes (97165, 97166, 97168), and guidance on typical service settings. The publication outlines billing benchmarks, coding distinctions between low, moderate, and high complexity occupational therapy evaluations, and common documentation elements that support medical necessity for this level of evaluation. Policy updates and payer-specific coverage nuances are summarized to help stakeholders understand reimbursement and utilization drivers at a national level.
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Billing Code Overview
CPT code 97167 denotes an occupational therapy evaluation of high analytic complexity. The service is an evaluation performed by an occupational therapist that requires advanced clinical decision‑making and includes an occupational profile, extensive review of medical and therapy history related to the current problem, and assessment of five or more physical, cognitive, or psychosocial performance factors that limit activity or restrict participation. Components of the evaluation may be completed with significant task modification or assistance and typically require approximately 60 minutes of face‑to‑face time with the patient, family, or both.
Service type: Occupational therapy evaluation (high complexity)
Typical site of service: Outpatient clinics, rehabilitation centers, inpatient rehabilitation units, and skilled nursing facilities where occupational therapy evaluations are provided.
National Reimbursement Benchmarks
Nationally, Medicare’s mean allowed rate for CPT 97167 sits at $104.20, which is modestly below BUCA’s average commercial mean of $177.40; that $73.20 gap highlights a material delta between traditional Medicare payment levels and an average commercial benchmark. Blue Cross Blue Shield and UnitedHealth Group have higher mean rates ($233.00 and $113.60 respectively) while Aetna and Cigna occupy lower commercial means, reinforcing a multi-tiered national market for this code.
Dispersion measured by the interquartile range (P75−P25) varies notably: Blue Cross Blue Shield shows the widest IQR at $161.70 ($289.80−$132.80), followed by UnitedHealth Group at $40.50 and BUCA at $106.20. Aetna and Cigna are tighter, with IQRs of $33.00 and $41.60 respectively, indicating more concentrated commercial pricing for those payers.