CPT 97167: Occupational Therapy Evaluation, High Analytic Complexity
Medicare pays $104 and commercial payers pay $177 on average nationally for this procedure.
CPT code 97167 describes an occupational therapy evaluation of high analytic complexity in which the occupational therapist conducts an extensive occupational profile and review of medical and therapy history, assesses five or more physical, cognitive, or psychosocial performance factors limiting activity or participation, and develops multiple treatment options; service type: occupational therapy evaluation (high complexity); typical site of service: outpatient clinic or other ambulatory care settings with approximately 60 minutes of face-to-face patient or family time.
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
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.