CPT 97165Occupational TherapyUntimed · per session

OT evaluation — low complexity

Occupational therapy session illustration

What CPT 97165 covers

CPT 97165 is the low-complexity occupational therapy evaluation: brief history, 1–3 performance deficits, and clinical decision-making of low complexity.

Complexity level is driven by the profile, number of deficits, and decision-making — not time alone.

Using 97165 on superbills

Straightforward pediatric referrals (e.g., isolated handwriting concern, no comorbidities) may fit 97165.
Most involved pediatric evaluations land at 97166 or 97167 — pick the level your documentation supports.

Documentation that supports it

Occupational profile, assessment results for the identified deficits
Clinical reasoning supporting the complexity level chosen

Common ICD-10 pairings

Examples seen in pediatric practice — always code the diagnosis that fits the client.

F82R27.8

FAQ

What makes an OT evaluation 'low complexity'?

Brief history with no comorbidities affecting performance, 1–3 performance deficits, and low-complexity decision-making. Document each element.

97166OT evaluation — moderate complexity 97167OT evaluation — high complexity 97168OT re-evaluation 97530Therapeutic activities

Educational reference only — not billing, coding, or legal advice. CPT® is a registered trademark of the American Medical Association. Verify current code definitions and payer policies before billing.