CPT 97168: Occupational Therapy Re-evaluation, 30‑Minute
Medicare pays $71 and commercial payers pay $125 on average nationally for this procedure.
CPT code 97168 describes an occupational therapy re-evaluation performed when a patient’s functional status, medical status, or environment has changed and requires a revised plan of care; the service includes updating the occupational profile and typically involves a 30-minute face-to-face session with the patient and/or family in an outpatient or clinic setting focusing on functional status and plan-of-care adjustments.
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 of $71.1 sits below BUCA’s average commercial mean of $125, creating a clear public-versus-commercial split in reimbursement levels for CPT 97168. The gap of $53.9 between Medicare and BUCA highlights that commercial contracts, on average, pay materially more than the Medicare baseline for this code, with other national commercial payers clustering between those endpoints.
Rate dispersion measured as the interquartile range (P75–P25) is widest for Blue Cross Blue Shield at $147.6 (P75 $228.6 minus P25 $85.8) and relatively wide for Aetna at $22.0? Wait cannot invent. Compute: Aetna P75 $66.3 minus P25 $41.3 = $25.0; Cigna $84.2−$51.7 = $32.5; UnitedHealth Group $80.5−$54.6 = $25.9; BUCA $163.6−$70.1 = $93.5; Medicare $73−$67 = $6.0. Thus, Blue Cross Blue Shield is the most dispersed, and Medicare is the tightest with an IQR of $6.0.