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CPT 97168: Occupational Therapy Re-evaluation, Revised Plan of Care
CPT code 97168 denotes an occupational therapy re-evaluation conducted when a patient’s functional status, medical condition, or environment has changed and a revised plan of care is required. Typically performed in a face-to-face encounter of about 30 minutes, this service updates the occupational profile and adjusts therapy goals and interventions. Nationally, re-evaluations like 97168 are central to ensuring care plans remain clinically appropriate and to aligning therapy services with evolving patient needs.
Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context and service delivery for 97168, comparisons to related evaluation and re-evaluation codes, and the typical settings where the service is rendered. The publication highlights billing considerations, common payer coverage themes, and coding relationships to other occupational and physical therapy evaluation codes.
This summary informs clinicians, coders, and policy analysts about the intended clinical use of CPT code 97168, how it differs from initial evaluations and shorter re-evaluations, and the national payer landscape relevant to reimbursement and coverage policies. Data not available in the input is explicitly noted where applicable within the full publication.
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Billing Code Overview
CPT code 97168 describes an occupational therapy re-evaluation that addresses changes in a patient’s functional status, environment, or medical condition and results in a revised plan of care. The service includes updating the occupational profile to reflect changes that affect therapy goals and interventions.
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Service type: Occupational therapy re-evaluation (face-to-face review and revision of plan of care)
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Typical site of service: Outpatient clinic, hospital outpatient department, skilled nursing facility, or other settings where occupational therapy is delivered in a face-to-face encounter; the service typically involves direct interaction with the patient and/or family and is performed at the point of care.
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.