97165 to 97168
Evaluation family
- Always-therapy codes, modifier GO
- Level set by three components, not the clock
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White paper · Occupational therapy billing
Occupational therapy billing guide 2027: from evaluation to units
Short answer: OT has its own evaluation code family, its own assistant modifier and its own dollar threshold. The 2017 rules hold: level by three components, units from total timed minutes, add GO. Around them: an OT threshold moving to $2,540, 15% off OTA minutes, RTM conditions tightening in January, and RAC topic 0228 reading KX claims.
97165 to 97168 · always therapy, GO
8 to 22 min · one timed unit
CO · 85% on OTA minutes
$2,480 → $2,540 · OT KX threshold, proposed
Edition
2027 guide
Focus
OT billing
Audience
OT owners · billers
Codes
97165 to 97168
Metric
$2,540 OT threshold
Length
14 min read
A PT template with the letters swapped leaks three ways
For the people who run an OT clinic's revenue cycle: owner, billing manager, front desk lead, coder. Every figure comes from a CMS page, manual or rule, citation beside it; proposed 2027 figures say so.
$2,480 then $2,540
Own threshold
- Separate OT accrual; moves every January
85% with CO
Own assistant modifier
- OTA minutes paid at 85% since 2022
- Independent of KX
RTM and RAC 0228
2027 pressure
- Three RTM conditions proposed for January; an approved review of KX claims
97165, 97166, 97167 and 97168: three components, all met
CPT replaced the single OT evaluation with three levels and one re-evaluation effective January 1, 2017; all four are always-therapy services carrying GO. Short descriptors cannot replace the long descriptors [7].
| Code | Occupational profile and history | Performance deficits | Clinical decision making | Typical time | Modifier |
|---|---|---|---|---|---|
| 97165 low | Brief history, record review for the presenting problem | 1 to 3 | Limited options, no comorbidities affecting occupational performance, no task modification | 30 min | GO |
| 97166 moderate | Expanded review plus physical, cognitive or psychosocial history tied to function | 3 to 5 | Several options, comorbidities may be present, minimal to moderate assistance | 45 min | GO |
| 97167 high | Record review plus extensive additional history | 5 or more | Multiple options, comorbidities present, significant assistance | 60 min | GO |
| 97168 re-evaluation | Update to the initial occupational profile for changes in condition or environment | Assessment of change in functional or medical status | Revised plan; documented change in function or significant plan change | 30 min | GO |
Typical face-to-face minutes by OT evaluation code
A guide to the visit, not a billing criterion. All four are untimed, one unit regardless of minutes; timed treatment in the same visit is counted separately [7].
30 min50% of high97165low
45 min75% of high97166moderate
60 min100%97167high
30 min50% of high97168re-evaluation
Initial evaluation levelsRe-evaluation
Habit 1: defaulting to 97166
The middle level for every new patient leaves the record short of three to five deficits; downcoded to 97165.
Habit 2: 97168 for a progress report
Reserved for a documented change in function or plan. A routine progress report is part of the visit.
Count the deficits
A numbered list in the evaluation; the count separates the levels and is the first thing a reviewer reads.
Name the comorbidities
Low complexity requires that none affects occupational performance. If one does, say which, and the level moves.
Describe the assistance
Assistance needed to complete the assessment is a required component. One sentence covers it.
The table everyone half-remembers
Claims Processing Manual Chapter 5, 20.2(C): total timed minutes in the day set the units; a single service is billable once it reaches 8 minutes. Untimed codes, the evaluation, 97010 and most group codes, bill one unit regardless [5].
Units billed by total timed minutes in a day
Continues in 15-minute steps beyond two hours.
1 unit8 through 22
8 to 22 min12%
2 units23 through 37
23 to 3712%
3 units38 through 52
38 to 52worked visit, 40 min
4 units53 through 67
53 to 6712%
5 units68 through 82
68 to 8212%
6 units83 through 97
83 to 9712%
7 units98 through 112
98 to 11212%
8 units113 through 127
113 to 12711%
0326495127 min
Minute band per unit countBand for the worked visit
Worked OT visit: 33 minutes of 97530 and 7 minutes of 97535
Manual example logic: 40 minutes sits in the 38 to 52 band, three units. Two for 97530 (first 30 minutes), one for 97535, because the remaining 3 minutes of 97530 is less than the 7 of 97535. The note shows total timed minutes and total treatment time; per-intervention minutes are not required [5].
97530therapeutic activities
33 min83% of time, 2 units
97535self-care and home management
7 min17%, 1 unit by largest remainder
Total timed38 to 52 band
40 min3 units billed
Timed servicesDay total, read off the table
TakeawayUnits come from the day's total, read off one table, allocated by largest remainder. Rounding each code on its own is the most common OT unit error. The therapy units calculator applies the table and shows where CO belongs.
GO, CO, KX, 59
CO and KX answer different questions and often share a line: who delivered the minutes, and whether the patient crossed the dollar line. Our OT KX and CO case study walks one beneficiary through both; the COTA modifier cut white paper models the 15%.
| Modifier | When it goes on the line | Payment effect | Source |
|---|---|---|---|
| GO | Every service under an OT plan of care, 97165 to 97168 included | None; omission causes rejection or wrong-discipline accrual | CMS therapy page, MM9782 |
| CO | Any service furnished in whole or in part by an OTA; CMS applies a de minimis standard | 85% of the otherwise applicable PFS amount from January 1, 2022 | CMS therapy page |
| KX | Services after the beneficiary passes the OT threshold for the year | Unlocks payment above the threshold; claims above it without KX are denied | CY 2027 PFS proposed rule |
| 59, or XE, XS, XP, XU | A second same-day service NCCI would bundle, when documentation supports it as distinct | Allows separate payment; misuse is a CARC 236 denial and an audit flag | X12 CARC list, NCCI policy |
2026 in force, 2027 proposed
CMS counts incurred expenses at the PFS rate less any multiple procedure payment reduction, across every OT provider the patient saw that year, hospital outpatient departments and critical access hospitals included. Your ledger is a floor [3].
OT KX modifier threshold, per beneficiary per year
Since the Bipartisan Budget Act of 2018 OT carries its own threshold. CY 2027: an estimated 2.5% MEI on $2,480, rounded to ten dollars, recomputed for the final rule. Medical review stays at $3,000 through 2027, indexed from 2028.
CY 2026 KX, OTin force
$2,480100%
CY 2027 KX, OTproposed
$2,540+2.4%
Targeted medical reviewthrough 2027
$3,000121% of the 2026 line
$0$1,000$2,000$3,000
In forceProposedReview selection line
Above $3,000Not a denial; the provider enters the pool CMS can select for review on statutory factors: high denial rates, billing patterns unlike peers, new enrollment, specific conditions, or a group that includes a flagged provider.
1
Read the running total before the visit
Eligibility response or contractor portal for the OT accrual to date; add planned charges at the PFS rate.
2
Append KX only when the record supports it
An attestation that medical necessity is documented. The KX documentation checklist lists what the record must show.
3
Watch $3,000 separately
Above the review line, expect a records request; RAC topic 0228 below says what it asks for.
Three clocks that gate payment
Medicare pays outpatient OT only under a plan a physician or NPP certifies. Benefit Policy Manual Chapter 15, 220.1.2: diagnoses, long-term goals, type, amount, duration and frequency. The therapist establishes it; the evaluation may be attached as part of it [6].
- 0Day 0Evaluation establishes the plan
- 30Within 30 daysPhysician or NPP certification; verbal order signed within 14 days
- 10Every 10 treatment daysProgress report; clock starts on day one, evaluation included
- 90At least every 90 daysRecertification, or sooner when the plan is significantly modified
- +Each visitTreatment note with total timed code minutes and total treatment time
Certification
30 calendar days from day one
Progress reports
Counted in treatment days
Certified period
Whatever the physician wrote, up to 90 days
Treatment notes
Every visit
Dated gatesRecurringCertified periodEvery visit
The evaluation is day one
- Timely within 30 calendar days of the first treatment day
- The manual counts the evaluation as that day
Certification length is what the physician wrote
- Any period up to 90 days; a 30-day certification on a 12-week plan recertifies at day 30
Progress reports count treatment days
- Not calendar days; a twice-weekly patient reports roughly every five weeks
Delayed certificationAccepted when the provider shows the plan was sent and the physician agreed later; denied if never certified. Make the certification queue a daily worklist, not a month-end sweep.
The code family, and three conditions proposed for January
RTM gives OT a recurring monthly line for a home program; 98979, 98984 and 98985 joined the sometimes-therapy list in the CY 2026 final rule. The CY 2027 proposed rule, published July 14, comments closed September 14, adds three conditions of payment from January 1, 2027 if finalized [3].
| Code | Component | Descriptor summary |
|---|---|---|
| 98975 | Set-up | Initial set-up and patient education on use of equipment |
| 98976 | Device supply | Respiratory system monitoring, 16 to 30 days in a 30-day period |
| 98977 | Device supply | Musculoskeletal system monitoring, 16 to 30 days in a 30-day period |
| 98978 | Device supply | Cognitive behavioral therapy monitoring, 16 to 30 days in a 30-day period |
| 98984, 98985, 98986 | Device supply | The 2 to 15 day counterparts added by the CPT Editorial Panel in September 2024 |
| 98979, 98980, 98981 | Treatment management | First 10 minutes, first 20 minutes, each additional 20 minutes per calendar month |
Established patients only
Condition 1
- The rule RPM returned to after the public health emergency
A separately reportable initiating visit
Condition 2
- In person or by telehealth, RTM discussed; billable on its own
Employed clinical staff
Condition 3
- Direct employees under general supervision only
- Third-party monitoring companies would not qualify
Comment solicitation, not a proposalCMS asks whether to collapse 17 remote monitoring codes into four G-codes, GRTM1 set-up and GRTM2 a monthly bundle requiring device supply, two or more days of data and 20 minutes of treatment management with a real-time interaction. Current codes remain the plan for January. Visit by visit: the Therapy Operator RTM issue.
Through December 31, 2027
Section 6209 of the Consolidated Appropriations Act, 2026 extended OT, PT and SLP telehealth, telephone codes 98966 to 98968 included, through December 31, 2027. From January 1, 2028 those disciplines cannot furnish it, and hospitals lose remote outpatient therapy to patients at home the same day [8].
| Item | Rule | Date |
|---|---|---|
| OT, PT, SLP and audiologists as telehealth practitioners | Permitted under the CAA 2026 extension | Through Dec 31, 2027 ends Jan 1, 2028 |
| Patient location | Anywhere in the United States and territories, then back to rural facility rules except behavioral health | Through Dec 31, 2027 |
| Modifiers BB and BC | BB for services through a contracted virtual platform; BC for services incident to a practitioner. No payment effect | From Jan 1, 2027 |
| October to November 2025 lapse | Claims paid as if the flexibilities never lapsed | Retroactive |
Modality changes the place of service, not the documentation rulesKeep the clocks running; tag every telehealth encounter BB or BC from January 1, 2027; plan for January 1, 2028 on any video home-visit line and watch for legislation that moves it. FAQ answers 2, 3, 16 and 17.
RAC topic 0228: read the policy list as the records request
Posted April 15, 2026: complex review, records requested and read, all A/B MACs, outpatient hospital and professional claims; coverage criteria, coding guidelines and appropriate use of KX [4].
| In scope for OT | Policy references named |
|---|---|
| 97165, 97166, 97167, 97168 evaluations and re-evaluation | Social Security Act 1861(g) outpatient OT; 1862(a)(1)(A) reasonable and necessary |
| 97110, 97112, 97530, 97535, 97542, 97750, 97760, 97761 | 42 CFR 410.59 OT conditions; 410.61 plan of treatment; 424.24 certification |
| 97014, 97032, G0281, G0282, G0283 modalities | Benefit Policy Manual Chapter 15, sections 220 and 230 |
| 29200 to 29550, 29799 strapping; 90901 biofeedback | Claims Processing Manual Chapter 5, sections 10 and 20.2 (units) |
| All of the above when KX is appended | Program Integrity Manual Chapter 3, 3.1 to 3.6.6; 42 CFR 405.929 and 405.930, failure to respond to a documentation request |
1
Build the KX packet template now
Plan of care, dated certification, latest progress report, treatment notes for the dates requested, a one-paragraph medical necessity statement. Miss the window and the claim is lost under 42 CFR 405.930 with no argument about the care.
2
Sample ten KX claims a month for the packet test
A packet that takes more than a day to assemble is a finding waiting to happen.
3
Log every additional documentation request with its due date
Late is the same as missing. Response-file checklist: the Therapy Operator issue on topic 0228.
Six reason codes, and who owns each
X12 descriptions as loaded for October 1, 2026 under Change Request 14492 [10]. Full map with remark codes: outpatient therapy CARC map. Visit limits, authorization vendors and rate notices by state: therapy payer matrix.
| CARC | X12 description (abridged) | Usual cause in OT | Owner |
|---|---|---|---|
| 151 | Information submitted does not support this many/frequency of services | Units exceed total timed minutes; frequency above the plan | Coder and treating OT |
| 4 | Procedure code inconsistent with the modifier used | GO missing or GP on an OT line; 59 on a pair that does not need it | Coder |
| 197 | Precertification, authorization, notification or pre-treatment absent | Commercial or Medicare Advantage visit beyond the authorized count | Front desk and authorization desk |
| 50 | Not deemed a medical necessity by the payer | KX without supporting documentation; maintenance care without skilled need | Treating OT and compliance |
| 236 | Procedure or modifier combination not compatible under NCCI | 97530 with 97140 or 97150 without a supported modifier | Coder |
| 119 | Benefit maximum for this time period reached | Payer visit limit; or Medicare threshold crossed without KX | Billing and authorization desk |
Takeaway
Own threshold, own assistant modifier, own evaluation family. Three clocks at once: 30 days to certify, 10 treatment days to report, 90 to recertify. Units from one table, not from rounding each code.
Seven checks before January
Pull ten evaluations and count the deficitsAgainst the level billed; look for the 97166 default.
Re-count units from total timed minutes on ten visitsPer-code rounding is the error to find.
Check GO on every line and CO only on OTA minutesBoth can sit beside KX.
Load $2,540 as a draft OT thresholdConfirm against the final rule; keep $3,000 for medical review.
Put the three clocks in the system, by patient, with an owner30, 10 treatment days, 90.
Run the RTM roster check and add BB and BC to the templateEstablished, initiating visit, employed staff; modifiers from January 1, 2027.
Where we fitOur occupational therapy billing services team works these rules daily. CorePulse, our verification engine, reads the 270/271 and flags the therapy benefit, visit limit and authorization before the first visit; Work Genie gives every claim an owner and a next action. OT beside PT or speech: the evaluation code guide and the CY 2027 impact note.
Frequently asked questions
What is the difference between 97165, 97166 and 97167?
The low, moderate and high complexity OT evaluation codes. The level depends on three components together: depth of history, number of performance deficits (1 to 3, 3 to 5, 5 or more) and complexity of clinical decision making, comorbidities and assistance included. Typical times 30, 45 and 60 minutes; time alone does not set the level. All carry GO.
How many units can I bill for 40 minutes of timed OT codes?
Three. Under Claims Processing Manual Chapter 5, 20.2, 38 through 52 total timed minutes support 3 units; if two services each ran over 15 minutes, each gets one and the third goes to the longer. Untimed codes bill one unit regardless.
What is the OT KX modifier threshold for 2026 and 2027?
CY 2026: $2,480, separate from the $2,480 combined PT and SLP amount. CY 2027: $2,540 proposed on an estimated 2.5 percent MEI increase, recomputed for the final rule. Targeted medical review stays at $3,000 through 2027.
What does the CO modifier do to payment?
CO marks OT services furnished in whole or in part by an OTA. Created for 2019; since January 1, 2022 paid at 85 percent of the PFS amount. Independent of KX; both can share a line.
Can an OT still bill Medicare telehealth in 2027?
Yes, through December 31, 2027 under section 6209 of the Consolidated Appropriations Act, 2026. From January 1, 2028 these disciplines can no longer furnish Medicare telehealth; modifiers BB and BC are required from January 1, 2027 with no payment effect.
- CMS, Therapy Services: KX thresholds, CQ/CO, RTM codes, CAA 2026 telehealth extension (modified March 10, 2026)
- CMS fact sheet, Calendar Year (CY) 2027 Medicare Physician Fee Schedule Proposed Rule (July 14, 2026)
- Federal Register public inspection, CMS-1847-P, CY 2027 PFS proposed rule (comments closed September 14, 2026)
- CMS, Approved RAC Topic 0228: Therapy Claims Billed with KX Modifier (April 15, 2026)
- Medicare Claims Processing Manual, Chapter 5, section 20.2, Reporting of Service Units With HCPCS
- Medicare Benefit Policy Manual, Chapter 15, sections 220.1.2, 220.1.3 and 220.3
- CMS MLN Matters MM9782, 2017 Annual Update to the Therapy Code List: 97161 to 97168 long descriptors
- CMS Telehealth FAQ, updated October 8, 2026
- CMS fact sheet, CY 2026 Physician Fee Schedule final rule (October 31, 2025)
- X12, Claim Adjustment Reason Codes (current list)
Checked October 25, 2026. Rules change; confirm against the source. Items marked proposed come from the CY 2027 PFS proposed rule and are not final until the final rule publishes.
Want your OT claims checked against these rules?
We review evaluations, timed units, CO and KX lines, certification dates and progress reports, and show what a RAC reviewer would find before one does.