CPT 97166
Global XXX ActiveOt eval mod complex 45 min
CPT 97166 Billing & Documentation Guide
CPT code 97166 (Ot eval mod complex 45 min) is classified under Physical Medicine with a global period indicator of XXX. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 1.54, a non-facility practice expense RVU of 1.46, and a malpractice RVU of 0.01, a total non-facility RVU of 3.01 and facility RVU of 3.01. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $103.67, though rates vary from $93.5 to $129.28 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 97166, ensure documentation supports medical necessity and the specific components required for the code's level of service. For E/M codes, document MDM (medical decision-making) elements: problems addressed, data reviewed, and risk. For procedural codes, document the indication, technique, and any complications. Always verify NCCI edits before bundling 97166 with related codes; this code has 10 PTP bundling relationships on file (see table below).
Payment Status & Global Period
Active code (paid under MPFS)
No global period (E/M and other non-procedural services)
MUE Limit (Medically Unlikely Edits)
Submitting more than 1 units of 97166 for the same patient on the same date triggers automatic line denial unless an appropriate modifier and supporting documentation justify the higher quantity.
RVU Breakdown, CPT 97166
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 1.54 | 1.54 |
| Practice Expense RVU | 1.46 | 1.46 |
| Malpractice RVU | 0.01 | 0.01 |
| Total RVU | 3.01 | 3.01 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 97166
State-level averages across all MAC localities. Non-facility rates typically apply to office-based services; facility rates apply to hospital outpatient / inpatient.
| State | Non-Facility | Facility | Range (Non-Fac) | Localities |
|---|---|---|---|---|
| California | $111.16 | $111.16 | $105.94 - $127.59 | 29 |
| Florida | $101.02 | $101.02 | $98.56 - $103.05 | 3 |
| Georgia | $98.44 | $98.44 | $95.33 - $101.54 | 2 |
| Illinois | $99.37 | $99.37 | $96.48 - $102.47 | 4 |
| Michigan | $97.7 | $97.7 | $96.34 - $99.06 | 2 |
| North Carolina | $97.15 | $97.15 | $97.15 - $97.15 | 1 |
| New York | $108.73 | $108.73 | $98 - $113.33 | 5 |
| Ohio | $96.3 | $96.3 | $96.3 - $96.3 | 1 |
| Pennsylvania | $100.03 | $100.03 | $96.52 - $103.53 | 2 |
| Texas | $100.04 | $100.04 | $96.12 - $103.43 | 8 |
Source: CMS PFSRVU 2026 · Updated 2026-04-01. Full locality-level detail available for all 53 states, contact us for custom reports.
NCCI Bundling Edits, CPT 97166
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 97166 on the same date of service, review the modifier indicator and payer policy before submission.
| Partner Code | Relationship | Modifier Allowed | Rationale |
|---|---|---|---|
| 0213T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0213T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0216T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0216T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0228T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0228T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0229T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0229T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0230T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0230T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
Frequently Asked Questions, CPT 97166
What does CPT code 97166 mean? +
CPT code 97166 represents: Ot eval mod complex 45 min. It's in the Physical Medicine category with a global period of XXX.
What is the Medicare reimbursement for CPT 97166? +
The 2026 Medicare national average non-facility payment for CPT 97166 is $103.67. Rates range from $93.5 to $129.28 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 97166? +
Medicine section spans a wide range: therapy services use GP/GO/GN (PT/OT/SLP plans of care) and KX (above cap with documentation). Drug administration uses JW (waste) and JZ (no waste). Professional/technical split applies to some diagnostic codes.
What bundling edits apply to CPT 97166? +
This code has 10 NCCI PTP bundling relationships. See the NCCI Bundling section below for full list.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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