CPT code 97167 – High-complexity occupational therapy evaluation

Key takeaways

CPT code 97167 is the high-complexity tier of the three-level OT initial evaluation family (97165, 97166, 97167), billable by an OT only, not an OTA.

All three required components must be documented. That means an extensive occupational profile, analysis of five or more performance deficits, and a high-complexity plan of care.

Medicare requires the GO modifier on every 97167 claim. The KX modifier is added once the annual therapy threshold is exceeded and services remain medically necessary.

Pabau, the practice management platform we build, includes claims management software that supports OT billing workflows, with electronic claim submission.

CPT code 97167: Official descriptor and clinical definition

CPT code 97167 is the AMA code for an occupational therapy evaluation of high complexity, with a typical time of 60 minutes. The official descriptor requires three components.

• An occupational profile and medical and therapy history, which includes a review of health, prior functional status and participation, including problem list and referral concerns.
• An assessment(s) that identifies 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.
• Clinical decision making of high complexity. This includes an analysis of the occupational profile, analysis of data from problem-focused assessments, and development of a plan of care.

Two things distinguish 97167 from its siblings. First, it requires identifying five or more performance deficits across physical, cognitive, or psychosocial domains. Second, the clinical decision-making must be documented as high complexity. The therapist’s reasoning, synthesis of assessment findings, and plan of care rationale all need to be explicitly connected in the record.

A note that lists deficits without explaining the reasoning behind the tier selection is a frequent audit target.

The code is billable only by a licensed occupational therapist (OT). An occupational therapy assistant (OTA) may contribute to the evaluation process, but the supervising OT must perform and document the evaluation. Only the OT’s NPI appears on the claim.

A billing workflow that locks the rendering provider to the OT on evaluation claims stops a common credentialing error before it reaches the payer.

What CPT code 97167 covers: Scope, inclusions, and exclusions

The three required components of a 97167 evaluation are the occupational profile, the performance analysis, and the plan of care. Each has a specific documentation threshold at the high-complexity tier.

• Occupational profile: Must be extensive. This means capturing the patient’s daily roles, priorities, values, and context. It also covers how the presenting condition affects multiple life domains, beyond a summary of the referral diagnosis. The history must cover prior functional status and current participation restrictions.
• Performance analysis: Must identify five or more performance deficits across physical, cognitive, or psychosocial skills. Each deficit must be linked to an activity limitation or participation restriction. Listing assessment scores alone is insufficient. The record must show how each deficit creates a functional consequence.
• Plan of care: Must reflect high-complexity clinical decision-making. The plan of care (POC) documents the therapist’s reasoning for the intervention approach and the anticipated progression. It also sets measurable goals tied to the identified deficits and justifies the frequency and duration of services.

A 97167 evaluation does not include re-evaluation (97164), group therapy, self-care or home management training (97535), or orthotic management (97760). Those are separately billable on subsequent visits. Billing any of them on the same date as 97167 may trigger a National Correct Coding Initiative (NCCI) edit, depending on the code pair. Check current NCCI edits before billing same-day.

CPT 97167 vs 97165 vs 97166: Choosing the right complexity tier

Tier selection is the most contested decision in OT evaluation billing, and the three codes are not interchangeable. Upcoding a 97165 or 97166 presentation to 97167 without meeting every high-complexity criterion is an audit risk. Use this table at the point of care.

The deficit count is necessary but not sufficient for 97167. The OT Potential CPT guide notes that the clinical decision-making must also independently meet high-complexity criteria. A patient with five deficits in a straightforward context who requires routine intervention may only support 97166.

The documented reasoning for complexity is what sustains the claim under audit. The chart below shows where the deficit counts overlap, which is exactly where that reasoning decides the code.

Documentation requirements for CPT code 97167

A 97167 note that passes payer scrutiny includes all of the following elements. Missing any one of them is grounds for downcoding on post-payment review.

1. Referral and presenting problem: Document the referral source, diagnosis, and specific functional concerns driving the evaluation. Connect the referral to the patient’s occupational roles.
2. Extensive occupational profile: Record the patient’s prior level of function across work, leisure, self-care, and social participation. Include what matters most to the patient. Profile breadth is what separates high from moderate complexity at the documentation level.
3. Five or more performance deficits, each with a functional link: Name each deficit, such as impaired grip strength, short-term memory deficits, or emotional dysregulation. Identify its domain (physical, cognitive, psychosocial) and state the resulting activity limitation or participation restriction.
4. Standardized assessments with results: List each tool used, the score or outcome, and how it supports the deficit identified. Do not list scores without interpretation.
5. High-complexity clinical decision-making narrative: This is the most frequently missing element. Write a synthesis paragraph explaining why the findings, the patient’s context, and the breadth of occupational impact together require high-complexity intervention planning.
6. Plan of care with measurable goals: Include short-term and long-term goals tied to specific deficits, intervention approach rationale, frequency, duration, and anticipated outcomes. The POC must reflect the complexity of the evaluation findings.
7. Medical necessity statement: State why skilled occupational therapy is necessary rather than supervision of a home program or non-skilled care.

Billing CPT code 97167 for Medicare: Modifiers, thresholds, and payer rules

Medicare Part B covers occupational therapy evaluations under the outpatient therapy benefit. Before submitting a 97167 claim, confirm insurance eligibility verification is complete and the patient’s therapy benefit has been checked against their plan year.

Three modifier rules govern nearly every 97167 Medicare claim.

• GO modifier (always required): Modifier GO indicates the service was furnished under an occupational therapy plan of care. It is mandatory on every 97167 Medicare claim, regardless of setting. A claim submitted without GO will reject.
• KX modifier (required once the therapy threshold is met): CMS sets an annual dollar threshold for outpatient therapy services. Once cumulative charges in the calendar year exceed it, the KX modifier certifies that continued services are medically necessary. The threshold is updated annually. Check the current year’s Medicare Physician Fee Schedule final rule for the exact figure.
• CQ modifier for OTA-furnished services: Medicare pays 85% of the allowed amount (a 15% reduction) for OTA-furnished services, flagged with CQ. 97167 itself is not billable by an OTA. The reduction applies to OTA services on later treatment visits, after the OT has completed the evaluation. Check your Medicare Administrative Contractor (MAC) for supervision requirements, which vary by state.

Medicare Advantage plans may impose prior authorization requirements for OT evaluations. Requirements vary by plan and geography, so check the specific plan’s prior authorization list before scheduling the evaluation. Electronic claim submission through a clearinghouse returns payer-specific error flags before a claim reaches the payer. That catches many of the modifier errors behind 97167 denials.

Reimbursement rates and RVU breakdown for 97167

The Medicare Physician Fee Schedule assigns relative value units (RVUs) to 97167 across three components. The national average allowed amount is derived from these RVUs multiplied by the annual conversion factor and a geographic practice cost index (GPCI) adjustment.

Both the conversion factor and GPCI values change annually, so check the current rate before you quote one. Use the CMS Physician Fee Schedule lookup tool to verify the current year’s allowed amount for your MAC jurisdiction.

Use the FastRVU lookup tool to retrieve current work, practice expense, and malpractice RVU values for 97167. It also shows the calculated Medicare allowable for your geographic area. Commercial payer rates are negotiated separately and may be higher or lower than the Medicare allowable depending on your contract.

CPT code 97167 and 97164: Same-day billing rules

CPT code 97164, the occupational therapy re-evaluation code, cannot be billed on the same date of service as CPT code 97167. The clinical logic is straightforward. 97167 is an initial evaluation. 97164 applies when a patient already in OT treatment needs a new evaluation after a significant change in condition.

NCCI edits bundle 97164 and 97167 together. A claim billing both on the same date will be denied without a modifier that overcomes the edit. No modifier is appropriate here because the services are clinically incompatible on a single date.

Bill 97167 on the evaluation date. Bill 97164 only when a documented change in the patient’s condition warrants a new evaluation later in the episode of care.

Clinical presentations that warrant 97167

High-complexity occupational therapy evaluations are appropriate when the patient’s clinical picture meets the five-deficit threshold and requires high-complexity decision-making. The following presentations commonly support 97167.

• Multiple comorbidities with overlapping functional impact: A patient with type 2 diabetes, peripheral neuropathy, depression, and moderate cognitive decline. Together, these affect self-care, home management, and community participation. ICD-10 diagnoses: E11.40, G62.9, F32.9, F06.70.
• Autism spectrum disorder with significant adaptive behavior deficits: Complex psychosocial, cognitive, and sensory-processing deficits across multiple occupational domains. ICD-10: F84.0.
• Traumatic brain injury with cognitive, behavioral, and physical sequelae: Deficits in memory, executive function, emotional regulation, motor control, and ADL independence across multiple performance areas. ICD-10: S06.2X9A (initial), S06.2X9D (subsequent).
• Multiple sclerosis with progressive functional loss: Combined physical, cognitive, and psychosocial deficits requiring complex care planning across changing disease stages. ICD-10: G35.B0 or G35.C0 (progressive forms) or G35.D (unspecified).
• Severe psychiatric diagnoses with extensive occupational impact: Schizophrenia or bipolar disorder affecting multiple life roles with significant psychosocial complexity. ICD-10: F20.9, F31.9.

Listing these diagnoses alone does not guarantee 97167. The evaluation note must still demonstrate five documented performance deficits and the high-complexity clinical reasoning that connects those deficits to the treatment plan. The diagnosis supports medical necessity, while the documented evaluation supports the complexity tier.

Confirm each diagnosis against the current ICD-10-CM code set before you submit. Codes change between fiscal years, as the October 1, 2025 split of G35 into subtype codes showed.

Common 97167 denial reasons and how to prevent them

Most 97167 denials fall into one of six patterns. Understanding denial management strategies specific to therapy codes helps OT practices catch these before claims leave the practice.

Building clean claim requirements into your OT billing workflow catches most of these before they turn into denials. Check the modifier set and any same-day code pairs before each 97167 claim goes out.

OT CPT codes commonly billed after a 97167 evaluation

The 97167 evaluation establishes the plan of care. Subsequent visits use treatment codes billed in 15-minute timed units or as untimed services. The following table shows the codes most frequently appearing on treatment visits after a high-complexity OT evaluation, with bundling notes.

Refer to the AAPC Codify CPT lookup for current NCCI bundling edit status on any code pair before billing. If you’re new to the claim cycle, start with the basics of medical billing. For timed codes, document the total timed minutes for each code in the session. Confirm you meet the 8-minute threshold before billing any 15-minute unit.

How claims management software protects 97167 reimbursement

When the evaluation note and the claim live in separate systems, the biller rebuilds the claim by hand. That is where a dropped GO modifier, an OTA listed as rendering provider, or a same-day 97164 slips through.

Pabau keeps the OT’s evaluation note, the patient record, and billing in one place. Its claims management software supports OT billing workflows, with electronic claim submission to Medicare and commercial payers.

The claim starts from the note your therapist already signed. Your biller reviews modifiers and the rendering provider before submission, so fewer 97167 claims come back as rejections weeks later.

Streamline OT billing and claims management with Pabau

Pabau’s claims management software supports occupational therapy billing workflows, with electronic claim submission from the system that holds your evaluation notes.

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Conclusion

Bill 97167 when the evaluation note proves the tier on its own. The diagnosis can suggest high complexity, but only the documented deficits and the reasoning that links them sustain the claim.

Before your next high-complexity evaluation, add a labeled clinical reasoning paragraph to your template and confirm GO sits on every Medicare OT claim. The trade-off is a few extra minutes of writing per evaluation, weighed against a downcode on post-payment review.

To see how Pabau keeps your evaluation notes and OT claims in one workflow, book a demo.

Continue your research

Billing OT in the home health setting? HCPCS code G0152 covers home health occupational therapy services and how to bill them.

Want to understand how claims clear the payer system? How a medical claims clearinghouse works explains the electronic submission pathway from practice to payer.

Managing claim denials across your OT caseload? Denial codes in medical billing provides a reference for reading and acting on CARC denial reasons on remittance advice.

Planning the first treatment visit? CPT code 97530 explains how to bill therapeutic activities in timed units.

Fitting an orthotic after the evaluation? CPT code 97760 covers orthotic management and training at the initial encounter.

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