CPT 97165: Occupational Therapy Evaluation, Low Complexity
CPT 97165 reports a low-complexity occupational therapy evaluation — a brief occupational profile, an assessment identifying 1-3 performance deficits, and low-complexity clinical decision making, typically about 30 minutes. It is untimed, billed once per evaluation. In 2026 Medicare pays about $100.54 non-facility (national, before locality adjustment).
- Code type
- OT evaluation (untimed, one per eval)
- 2026 Medicare
- ~$100.54 (non-facility)
- Timed?
- No — billed once, not per 15 min
- Therapy cap
- Counts toward 2026 KX threshold ($2,480 OT)
What is CPT 97165 used for?
CPT 97165 is a low-complexity occupational therapy evaluation, the code that opens an OT plan of care for a straightforward patient. It is one of three OT evaluation tiers and, like the PT codes, is untimed — billed once per initial evaluation rather than per 15 minutes.
The level is driven by the number of performance deficits identified and the complexity of the occupational profile, assessment, and clinical decision making.
What are the three OT evaluation tiers?
| Code | Complexity | Performance deficits | Typical time |
|---|---|---|---|
| 97165 | Low | 1-3 | ~30 min |
| 97166 | Moderate | 3-5 | ~45 min |
| 97167 | High | 5 or more | ~60 min |
Each tier requires the occupational profile, the assessment of occupational performance, and the clinical decision making to all reach that level. The deficit count is the most concrete differentiator between tiers.
How much does 97165 pay in 2026, and how does the OT cap work?
All three OT evaluation tiers pay the same Medicare rate — about $100.54 non-facility in 2026 before locality adjustment. The evaluation counts toward occupational therapy's own 2026 KX modifier threshold of $2,480, which is separate from the PT/SLP threshold. Once a beneficiary's OT spending crosses it, append KX to attest medical necessity. Check your locality figure with the Medicare fee calculator.
How do you choose the right OT evaluation level?
All three components must reach a tier for you to bill it — if only the deficit count is high but the profile and decision making are low, code low. The evaluation sets the medical necessity basis for the timed treatment codes that follow, such as 97110, 97530, and 97112. The physical therapy counterpart is 97161.
Frequently asked questions
97165 fits a brief occupational profile and history, an assessment that identifies 1-3 performance deficits (relating to physical, cognitive, or psychosocial skills), and clinical decision making of low complexity. Typical face-to-face time is about 30 minutes. All three areas must meet the low tier.
Yes. Occupational therapy has its own 2026 KX modifier threshold of $2,480, separate from the combined $2,480 physical therapy and speech-language pathology threshold. OT spending does not count against the PT/SLP pool and vice versa.
No. Like the PT evaluation codes, the three OT evaluation tiers are untimed — one evaluation code per initial evaluation. The listed times (about 30, 45, and 60 minutes) are typical values, not billing thresholds, so the 8-minute rule does not apply.
Sources & further reading
Reviewed by the ImmediCare Solutions RCM team
Certified billers and coders handling claims across 50+ specialties nationwide. This entry is reviewed against current payer policy and CMS rules. Last review: Jul 5, 2026.
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