Evaluation & management · Hand
Occupational therapy evaluation of moderate complexity, covering an expanded history, assessment of several performance deficits, and a care plan with some modification options.
- Medicare
- $100.54
- Work RVU
- 1.54
- Global, days
- Region
- Hand
Documentation requirements
What must appear in the operative or office note to support the claim.
Source · Editorial brief grounded in 3 cited references ↓
- Occupational profile and medical history review
- Performance deficits identified (physical, cognitive, or psychosocial)
- Standardized assessments with scores
- Clinical decision making and analysis of options
- Plan of care with goals and frequency
- Total evaluation time
Applicable modifiers
Modifiers commonly billed with this code.
Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual
What this code covers
Source · Editorial summary grounded in 3 cited references ↓
97166 is the moderate-complexity occupational therapy evaluation. It sits between the low (97165) and high (97167) levels. The level depends on the history, the number of performance deficits, and the clinical decision making, with about 45 minutes as the typical time face to face with the patient and family.
Ortho practices with hand therapy bill it after flexor tendon repair, distal radius fracture fixation, carpal tunnel release with complications, or reverse shoulder replacement when ADL function is the focus. A patient with deficits in grip, dressing, and work tasks, plus a comorbidity like diabetes affecting healing, often fits moderate complexity.
The common problem is picking the level by time alone. Time is a guide; the elements decide it. Document the occupational profile, the deficits found, the standardized tests used (grip dynamometry, QuickDASH), and the plan. Use the GO modifier for Medicare. Re-evaluation is 97168, not another 97166. Only one evaluation per episode unless there is a new diagnosis or significant change.
RVU & reimbursement
Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.
Source · CMS Physician Fee Schedule, RVU26A · January 2026
Work RVU vs. total RVU
The work RVU (1.54) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (3.01) adds practice overhead and malpractice, and is what drives the Medicare payment below.
| Work RVU | 1.54 |
| Practice expense RVU | 1.46 |
| Malpractice RVU | 0.01 |
| Total RVU | 3.01 |
| Medicare national rate | $100.54 |
| Global period | days |
Payment by site of service
Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.
Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026
| Setting | Medicare rate (national) |
|---|---|
Office (PFS non-facility) Procedure performed in physician's office | $100.54 |
Common denial reasons
The recurring reasons claims for CPT 97166 get rejected.
Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓
- Complexity level not supported by documented elements
- Billed as a re-evaluation (should be 97168)
- Second evaluation in the same episode without new diagnosis
- Missing GO modifier
- Plan of care not certified for Medicare
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 3 cited references ↓
01What makes an OT evaluation moderate complexity?
02Can a hand therapist bill 97166?
03What code is used for an OT re-evaluation?
Sources & references
Editorial content was developed using the following public sources.
Mira Scribe
Mira Scribe pulls the occupational profile, deficits, test scores, and plan into the note, so the moderate complexity level is supported by the record and not just the clock.
See how Mira captures CPT 97166 documentation