How much does Medicare pay for CPT 97165?

Medicare allowed an average of $100.93 per service and paid $75.63 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $214.01, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 97165?

Evaluation for occupational therapy, typically 30 minutes. It was billed 162,770 times to 153,253 Medicare beneficiaries by 4,572 providers in 2024.

Does 97165 pay differently in an office than a hospital?

Yes. The allowed amount averaged $100.93 in an office setting and $99.99 in a facility. The office rate is generally higher because the practice supplies the room, staff and equipment out of that single payment; in a hospital those are billed separately by the facility.

Which specialty bills 97165 most?

Occupational Therapist in Private Practice, with 158,699 services from 4,450 clinicians. Next are Orthopedic Surgery, Hand Surgery, Physical Therapist in Private Practice.

CPT 97165

Evaluation for occupational therapy, typically 30 minutes

$100.93Medicare-allowed amount per service, averaged across 162,770 services

Providers submitted

$214.01

Asking price, not received

Medicare allowed

$100.93

The fee schedule figure

Medicare paid

$75.63

Balance is patient coinsurance

Providers submitted an average of $214.01 for this code and Medicare allowed $100.93 — 2.1× less. That gap is normal and means nothing on its own: Medicare pays its fee schedule regardless of what is billed, so the submitted figure describes a hospital chargemaster, not a price anyone paid. Of the allowed amount Medicare paid $75.63 (75%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $100.93
Hospital / facility: $99.99

The office rate is higher because the practice supplies the room, staff and equipment out of that payment. In a hospital the facility bills those separately, so the clinician's share is smaller — the total cost to Medicare is usually higher, not lower. 162,520 services were billed in an office setting and 250 in a facility.

Services: 162,770
Beneficiaries: 153,253
Providers billing it: 4,572
Total allowed: $16,428,376

What Medicare pays for CPT 97165

Across 162,770 services billed by 4,572 providers to 153,253 beneficiaries, Medicare allowed an average of $100.93 per service. The allowed amount is the figure that matters: it is what Medicare and the patient together owe, set by the fee schedule and adjusted for local practice costs. What a provider chose to submit has no bearing on it.

Who bills 97165

Specialty	Services	Beneficiaries	Avg allowed	Providers
Occupational Therapist in Private Practice	158,699	149,351	$101.03	4,450
Orthopedic Surgery	1,475	1,432	$99.99	47
Hand Surgery	1,348	1,303	$96.99	33
Physical Therapist in Private Practice	530	501	$101.70	12
Neurology	177	151	$108.03	8
Sports Medicine	107	102	$94.60	3
Physical Medicine and Rehabilitation	92	89	$27.04	3
Physician Assistant	69	56	$74.08	3
Otolaryngology	48	48	$101.65	2
Unknown Supplier/Provider Specialty	45	44	$99.22	1
Urology	38	38	$96.35	1
Rheumatology	35	32	$85.07	2
Family Practice	20	20	$92.09	1
Plastic and Reconstructive Surgery	20	19	$91.67	1
Optometry	16	16	$102.12	1

97165 reimbursement by state

Two different numbers. Allowed is what Medicare actually allowed in that state, which includes the local practice-cost adjustment. Standardized strips that geographic adjustment out of the payment, so it is the column to use when comparing states — a difference there reflects how the code was billed, not what it costs to run a practice locally.

State	Services	Allowed	Standardized pmt	Providers
New York	17,062	$109.49	$74.39	427
California	13,611	$110.19	$74.01	324
Florida	12,792	$98.90	$75.20	257
New Jersey	9,862	$108.41	$74.81	316
Illinois	8,385	$99.94	$74.42	264
Minnesota	5,928	$99.24	$74.34	192
Pennsylvania	5,566	$99.10	$75.36	153
North Carolina	5,541	$95.77	$74.12	153
Washington	4,976	$103.36	$72.71	162
Virginia	4,812	$100.00	$75.15	129
Georgia	4,469	$95.95	$75.19	140
Arizona	4,387	$97.42	$73.98	101
South Carolina	4,299	$94.49	$75.31	107
Texas	4,200	$97.36	$74.59	119
Maryland	3,771	$104.49	$73.77	107
Colorado	3,605	$101.76	$74.68	101
Ohio	3,468	$94.54	$75.36	104
Massachusetts	3,459	$105.17	$74.09	79
Tennessee	3,023	$93.09	$75.75	86
Indiana	2,985	$94.02	$73.31	86
Alabama	2,566	$92.16	$75.67	85
Louisiana	2,432	$93.01	$74.76	71
Arkansas	2,387	$91.47	$75.88	62
Mississippi	2,164	$91.27	$74.12	52
Wisconsin	1,987	$95.98	$73.45	85
Connecticut	1,963	$105.04	$74.71	68
Michigan	1,854	$96.52	$74.63	76
Nebraska	1,675	$95.03	$72.61	51
Oregon	1,641	$100.38	$72.74	50
Iowa	1,639	$94.36	$75.96	55
Missouri	1,453	$96.11	$73.66	54
Kansas	1,387	$93.03	$75.31	32
Kentucky	1,208	$93.26	$74.22	42
Wyoming	1,145	$97.84	$72.49	28
Delaware	1,012	$97.99	$75.24	23
Nevada	972	$100.07	$73.43	37
North Dakota	939	$99.17	$72.90	30
New Hampshire	810	$101.51	$73.86	20
South Dakota	779	$98.14	$74.94	25
Montana	778	$98.97	$74.65	23
New Mexico	697	$94.16	$72.90	13
Rhode Island	682	$101.27	$74.96	28
Alaska	668	$125.45	$75.06	22
Idaho	656	$95.29	$72.60	18
Maine	651	$96.74	$72.26	27
Hawaii	632	$103.10	$73.39	22
Oklahoma	485	$93.56	$73.29	17
Utah	467	$94.39	$76.96	22
District of Columbia	421	$109.95	$75.50	13
Vermont	200	$99.23	$71.28	5
West Virginia	194	$91.86	$75.59	8
U.S. Virgin Islands	25	$97.02	$66.14	1

Related codes

97110Therapy procedure$22.78
97112Therapy procedure to re-educate brain-to-nerve-to-muscle function$27.06
97140Therapy procedure$20.62
97116Therapy procedure for walking training$21.87
97150Therapy procedure in a group setting$13.60
97161Evaluation for physical therapy$99.49
97162Evaluation for physical therapy$99.21
97113Therapy procedure$27.67
97130Therapy procedure for a range of mental processes$21.18
97164Re-evaluation for physical therapy$68.54
97124Therapy procedure$25.23
97129Therapy procedure for a range of mental processes$21.82

Billing this code is not the same as earning it

An allowed amount is revenue to a practice, not income to a clinician. It funds staff, premises, equipment and supplies before anyone is paid. What clinicians actually earn is published separately by the Department of Labor, and what industry pays them is published separately again by CMS — this site carries both.

What doctors are paid →·Look up a clinician →·All procedure codes →

Where this comes from. CMS Medicare Physician & Other Practitioners, by Provider and Service, 2024. It covers fee-for-service Original Medicare Part B only — not Medicare Advantage, not Medicaid, and not commercial insurance, which typically pays more for the same code.

How it is averaged. CMS publishes one average per provider per code. Every figure here is re-weighted by the number of services, so a clinician who billed the code 4,000 times counts 4,000 times more than one who billed it twice. CMS also suppresses any provider-code pair with fewer than 11 beneficiaries, so low-volume practice is missing from these totals by design.