CPT 97168Occupational TherapyUntimed · per session

OT re-evaluation

Occupational therapy session illustration

What CPT 97168 covers

CPT 97168 covers OT re-evaluation: an update to the plan of care based on a documented change in functional status or new clinical findings.

Using 97168 on superbills

Bill when there is a meaningful change — not for routine progress notes or annual paperwork.
Common triggers: plateau requiring goal revision, post-surgical status change, or significant new findings.

Documentation that supports it

Comparison to prior findings, revised goals, and updated plan of care

Common ICD-10 pairings

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

F82G80.9

FAQ

Is a re-evaluation required every 6 months?

No universal rule — payer and state practice-act requirements vary. Bill 97168 when a true re-evaluation occurs, not on a calendar schedule alone.

97165OT evaluation — low complexity 97166OT evaluation — moderate complexity 97167OT evaluation — high complexity

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.