CPT 97167: Occupational Therapy Evaluation, High Analytic Complexity - OpenPayer

Summary & Overview

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.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare97167CPToccupational-therapyevaluationhigh-analytic-complexitytherapy-codingmedical-necessityrehabilitation

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.

Clinical & Coding Specifications

Clinical Context

A 68-year-old right-handed patient presents to outpatient occupational therapy after an ischemic stroke leading to residual right-sided hemiparesis and difficulty ambulating. The occupational therapist performs a high-complexity evaluation billed with 97167. The visit includes an occupational profile with patient and family interview about prior function, goals, home environment, and current symptoms; an extensive review of medical records and prior therapy notes related to the stroke and subsequent orthopedic aftercare; and assessment of five or more performance deficits including range of motion, muscle strength, balance, coordination, cognition (attention and memory), and activities of daily living (dressing, bathing, transfers). Tasks are modified with physical assistance and adaptive equipment trials. The OT documents multiple treatment options (e.g., task-specific functional training, adaptive equipment prescription, home exercise program, caregiver education) and completes approximately 60 minutes of face-to-face time with the patient and family. Typical workflow includes record review, standardized and task-based assessments, care planning discussion with family, and documentation of plan of care. Usual site of service is outpatient clinic or home health visit depending on patient mobility and follow-up needs.

Coding Specifications

Modifier	Description	When to Use
`11`	Professional component

CPT 97550: Caregiver Training for Functional Deficits, First 30 Minutes

97598

CPT 97598: Additional Wound Debridement in Outpatient Rehabilitation

97150

CPT 97150: Group Therapeutic Procedures in Physical Medicine and Rehabilitation

cpt-29065-long-arm-cast-application-upper-lower-arm

CPT 29065: Long Arm Cast Application for Arm Fractures

cpt-29131-dynamic-finger-splint-application

CPT 29131: Dynamic (Hinged) Finger and Hand Splint Application

29086

CPT 29086: Application and Fabrication of Finger Cast

cpt-29049-figure-of-eight-cast-application-upper-extremity

CPT 29049: Figure-of-Eight Cast Application for Upper Extremity

29355

CPT 29355: Application of Long Leg Cast (Thigh to Toes)

29345

CPT 29345: Application of Long Leg Cast Including Knee, Leg, and Foot

97116

CPT 97116: Gait Training Therapeutic Procedure

Showing 1–10 of 191

Taxonomy Code	Specialty	Notes
`225X00000X`	Occupational Therapist	Primary provider credential for performing and billing `97167`.
`225XE0001X`	Environmental Modification Occupational Therapist	Applies when evaluation includes extensive home environment or adaptive equipment assessment.
`225XF0002X`	Feeding, Eating & Swallowing Occupational Therapist	Applies when evaluation includes feeding or swallowing-related occupational performance impairments.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`R26.2`	Difficulty in walking, not elsewhere classified	Directly describes gait impairment assessed during the OT evaluation and influences mobility and safety recommendations.
`M62.81`	Muscle weakness (generalized)	Muscle weakness is assessed across extremities and trunk as a contributor to activity limitations and treatment planning.
`G81.90`	Hemiplegia, unspecified affecting unspecified side	Hemiplegia is a common reason for comprehensive OT evaluation to address unilateral motor and functional deficits.
`I69.351`	Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side	Specifies post-stroke hemiparesis; guides targeted interventions for dominant-side impairment and ADL retraining.
`Z47.89`	Encounter for other orthopedic aftercare	Relevant when OT evaluates functional limitations related to orthopedic aftercare concurrent with neurological deficits.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`97165`	Occupational therapy evaluation, low complexity	Alternative lower complexity evaluation when fewer performance deficits are present or less clinical decision-making is required.
`97166`	Occupational therapy evaluation, moderate complexity	Used when clinical decision-making and number of assessed performance deficits meet moderate rather than high complexity criteria.
`97168`	Occupational therapy re-evaluation	Used for subsequent formal re-evaluation to assess progress and revise the plan of care after the initial `97167`.
`97530`	Therapeutic activities, direct (one-on-one) patient contact	Common follow-up treatment code for functional, task-oriented interventions that are selected after the `97167` evaluation.

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