2017 New Occupational Therapy Evaluation Coding Overview | | Medical Practice Consultant

2017 New Occupational Therapy Evaluation Codes

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Effective January 1st 2017, we have 3 New Occupational Therapy Evaluation Codes

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Per CPT, these are the components in selecting the appropriate level of Occupational Therapy service. The first 3 components are very important that you must make sure they are appropriately scored. Insurance payers are looking at these 3 components if the right level code has been selected.

1. Occupational profile and client history2. Assessments of occupational performance3. Medical decision making4. Development of plan of care



So let’s look at each of these components and see

how we choose the appropriate code level.



1. Occupational profile and client history (medical and therapy)

Levels for this Component includes:● Low Complexity (Brief)● Moderate Complexity (Expanded)● High Complexity (Extensive)



2. Assessments of occupational performanceLevels of Assessment of Occupational Performance:● Low Complexity (Problem-Focused)● Moderate Complexity (Detailed)● High Complexity (Comprehensive)



2.1 CPT® Definition of Performance DeficitsPerformance deficits refer to the inability to complete activities due to the lack of skills in one or more of the categories below (i.e., relating to physical, cognitive, or psychosocial skills):● Physical skills refer to impairments of* body structure or body function (e.g., balance,

mobility, strength, endurance, fine or gross motor coordination, sensation, dexterity). * AOTA regards “impairments of” as a typographical error and will be seeking revision because skills are not impairments.

● Cognitive skills refer to the ability to attend, perceive, think, understand, problem solve, mentally sequence, learn, and remember, resulting in the ability to organize occupational performance in a timely and safe manner. These skills are observed when a person (1) attends to and selects, interacts with, and uses task tools and materials; (2) carries out individual actions and steps; and (3) modifies performance when problems are encountered.



2.2 CPT® Definition of Performance Deficits● Psychosocial skills refer to interpersonal interactions,

habits, routines and behaviors, active use of coping strategies, and/or environmental adaptations to develop skills necessary to successfully and appropriately participate in everyday tasks and social situations.



3.1 Medical Decision Making CPT® Code CPT® Language● Low Complexity (97165)● Clinical decision making of low complexity, which includes an analysis of the occupational

profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.

● Moderate Complexity (97166)● Clinical decision making of moderate analytic complexity, which includes an analysis of the

occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable completion of evaluation component.



3.2 Medical Decision Making CPT® Code CPT® Language● High Complexity (97167)● Clinical decision making of high analytic complexity, which includes an

analysis of the occupational profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient may present with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.



4. Then comes the ….

DEVELOPMENT OF PLAN OF CARE



Let’s look at the NEW CPT CODES

for OT Evaluation for 2017



CPT CODE 97165 – Occupational therapy evaluation, low complexity, requiring these components:● An occupational profile and medical and therapy history, which includes a brief history

including review of medical and/or therapy records relating to the presenting problem;● An assessment(s) that identifies 1-3 performance deficits (i.e., relating to physical, cognitive,

or psychosocial skills) that result in activity limitations and/or participation restrictions; and● Clinical decision making of low complexity, which includes an analysis of the occupational

profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family.



CPT CODE 97166 – Occupational therapy evaluation, moderate complexity, requiring these components:● An occupational profile and medical and therapy history, which includes an expanded review

of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance;

● An assessment(s) that identifies 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and

● Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family.



CPT CODE 97167 – Occupational therapy evaluation, high complexity, requiring these components:● An occupational profile and medical and therapy history, which includes review of medical

and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance;

● An assessment(s) that identifies 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and

● Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family.



ONE SINGLE CODE FOR OCCUPATIONAL THERAPY RE-

EVALUATIONCPT CODE 97168



CPT CODE 97168 – Re-evaluation of occupational therapy established plan of care, requiring these components:● An assessment of changes in patient functional or medical status with revised plan of care;● An update to the initial occupational profile to reflect changes in condition or environment

that affect future interventions and/or goals; and● A revised plan of care. A formal reevaluation is performed when there is a documented

change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family.



KEEP IN MIND!



➔ These new codes are all untimed codes, and when recording time for Medicare, the minutes allocated for the evaluation are tallied as part of the “total treatment minutes,” which includes timed codes and untimed codes.

➔ Since these codes are untimed codes, the time (minutes) rendered during the evaluation are now part of the “total minutes” of treatment time – this includes both the untimed and timed codes.



➔Use these new therapy evaluation codes for Medicare and commercial payers;

➔Workers’ Comp and MVA liability may still be using 97003/97004



The Medicare occupational therapy cap is

$1,980.00 for 2017



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References:

● 2017 CPT Manual (CPT is a Trademark and Owned by the American Medical Association)

● https://www.cms.gov/Medicare/Billing/TherapyServices/index.html?redirect=/therapyservices

● https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3654CP.pdf


Date post:	26-Jan-2017
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2017 New Occupational Therapy Evaluation Coding Overview | | Medical Practice Consultant

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