Using CPT Codes for Occupational Therapy Evaluation

The U.S. occupational and physical therapy services market was valued at $54.06 billion in 2023 and is projected to reach an impressive $128.17 billion by 2032. This growth is primarily driven by the increasing prevalence of chronic diseases and a growing awareness among patients about the importance of managing musculoskeletal disorders. 

As medical practitioners, you’re on the frontlines of these essential services, equipped with a variety of tools to support patient care—one of the most critical tools being CPT codes. These codes, updated annually by the American Medical Association, ensure that the complex and personalized nature of OT evaluations is communicated clearly and consistently across the healthcare system. 

From defining the level of evaluation to justifying specific therapeutic approaches, OT evaluation CPT codes are integral not only for accurate record-keeping but also for obtaining appropriate reimbursement. Continue reading to gain comprehensive insights into CPT codes for occupational therapy evaluations. 

Understanding Occupational Therapy Evaluation Code

Occupational Therapy evaluation involves a thorough assessment of a patient’s physical, cognitive, and emotional abilities to create a tailored treatment plan that enhances their ability to perform daily activities. This evaluation is a critical first step in occupational therapy, helping to identify specific needs, set goals, and measure progress over time.

According to a report by USN, employment for occupational therapists is projected to grow by 11.5% between 2022 and 2032.  Many are choosing this career for its rewarding nature, as it allows professionals to make a significant impact on individuals’ quality of life through personalized care and support.

OT codes help you describe the scope and complexity of the assessment, ranging from low to high complexity. They are essential for ensuring accurate billing, reimbursement, and patient record-keeping. Let’s dive deeper into the evaluation complexity levels and their CPT codes.

Common CPT Codes in Occupational Therapy

Occupational therapists use specific CPT codes to document evaluations and treatment procedures accurately. These codes ensure proper communication with insurance providers and facilitate seamless billing processes. Below is a concise list of frequently used CPT codes in occupational therapy practice.

In occupational therapy, you know that evaluations can’t follow a one-size-fits-all approach. Each patient has unique needs, requiring different levels of assessment to understand their condition fully. To make this process transparent and precise, evaluation codes are divided into various levels of complexity. Let’s explore each level. 

Levels of Evaluation Complexity

These complexity levels guide you in documenting the intensity of each patient’s situation based on criteria such as the number of performance areas you assess, the clinical judgment required, and the extent of modifications needed in the treatment plan. By understanding these distinctions, you can ensure your documentation reflects the tailored care each patient deserves.

1. Low Complexity Evaluation (CPT Code 97165)

CPT Code 97165 is used when conducting a low-complexity occupational therapy evaluation. This code applies to patients with relatively stable conditions and limited impairments. To ensure accurate reimbursement when using this code, your documentation must reflect the specific characteristics of a low-complexity evaluation. Here’s what you need to include:

• Brief Medical History: Document a simple, focused medical history relevant to the current evaluation without in-depth detail.
• Identifies 1-3 Performance Deficits: The evaluation should document 1 to 3 specific performance deficits—such as physical, cognitive, or psychosocial skills—that limit the patient’s activities or participation in daily life.
• Typical Duration: 30 Minutes: Ensure that the evaluation duration aligns with this code’s typical timeframe, around 30 minutes.
• Low Analytical Skills Required: Describe the straightforward nature of the clinical reasoning involved, with minimal complexity in the analysis.
• Standardized Assessments Used: Use basic, standardized tools and document their application without extensive customization.
• Minimal Modifications in Procedures: Indicate that standard assessment procedures were followed, with few or no modifications required for the patient.

2. Moderate Complexity Evaluation (CPT Code 97166)

This code applies to cases where the patient’s condition involves more nuanced and layered impairments than a low-complexity evaluation would address. To qualify for reimbursement under this code, your documentation should clearly demonstrate a moderate level of complexity in the patient’s condition and the evaluation process. Here are the key characteristics required:

• Expanded Medical History: Document a more detailed medical history, covering relevant past conditions and treatments that inform the current evaluation.
• Identifies 3-5 Performance Deficits: Highlight 3 to 5 specific deficits in areas like physical, cognitive, or psychosocial skills that result in activity limitations or participation restrictions.
• Typical Duration: 45 Minutes: The evaluation generally requires about 45 minutes, reflecting the moderate complexity of the case.
• Moderate Analytical Skills Required: Show the need for clinical judgment that involves moderate complexity in reasoning, with some adjustments based on the patient’s specific needs.
• Combination of Standardized and Non-Standardized Assessments: Document the use of both basic standardized assessments and more tailored tools or approaches.
• Modifications to Procedures as Needed: Detail any minor modifications to the standard assessment protocols to accommodate the patient’s unique needs.

3. High Complexity Evaluation (CPT Code 97167)

For patients with complex and multifaceted conditions, you’ll turn to CPT Code 97167 for a high-complexity occupational therapy evaluation. This code is reserved for cases that require an in-depth assessment, often involving multiple areas of impairment and significant clinical judgment. To ensure reimbursement for a high-complexity evaluation, your documentation must reflect the extensive and detailed nature of the patient’s needs. Here’s what you’ll need to include:

• Comprehensive Medical History: Document a thorough medical history, capturing detailed background on the patient’s condition, treatments, and any complicating factors.
• Identifies 5 or More Performance Deficits: Specify 5 or more performance deficits across physical, cognitive, and/or psychosocial areas that significantly limit the patient’s daily activities and participation.
• Typical Duration: 60 Minutes: High-complexity evaluations generally require around 60 minutes to cover the comprehensive scope needed.
• High-Level Analytical Skills Required: Emphasize the need for complex clinical reasoning, with significant adjustments and considerations based on the patient’s intricate needs.
• Use of Standardized and Custom Assessments: Document both standardized tests and more customized assessments tailored to the patient’s unique profile.
• Substantial Modifications to Procedures: Describe any extensive modifications made to standard evaluation protocols to address the patient’s specific limitations and requirements.

Want to deepen your understanding of CPT codes? Head over to SpryPT, where you will find explanations and billing guidelines for different CPT codes. Let us now examine the details of Reevaluation CPT Code 97168.

Reevaluation and Common Mistakes (CPT Code 97168)

When conducting a reevaluation in occupational therapy, CPT Code 97168 is your go-to for documenting this updated assessment. Reevaluations are typically performed when there’s a notable change in the patient’s condition or if there’s a need to adjust the treatment plan based on progress or new goals. However, to secure reimbursement for reevaluations, it’s crucial to ensure that your documentation accurately reflects the specific requirements of this CPT code. Avoiding common mistakes can make a big difference in billing success. Here’s what you need to include:

• Updated Medical History and Condition Review: Provide an updated overview of the patient’s medical history, particularly any changes since the last evaluation.
• Reassessment of 1-3 Performance Deficits: Identify and document 1 to 3 areas where the patient’s abilities have changed, such as physical, cognitive, or psychosocial skills.
• Revision of Treatment Goals: Outline any adjustments to treatment goals based on the patient’s progress or changes in condition.
• Typical Duration: 30 Minutes: Ensure that the reevaluation aligns with the expected duration of around 30 minutes.
• Moderate Analytical Skills Required: Indicate the level of clinical judgment needed to reassess and adapt the treatment plan without the complexity of an initial evaluation.
• Updated Treatment Plan: Document a clear, revised treatment plan that reflects the new goals and strategies for the patient’s ongoing care.

For more details on OT evaluation complexities, be sure to check out AOTA’s(American Occupational Therapy Association) YouTube video!

‍

What makes an Occupational Therapist a great leader? Take just five minutes to explore SpryPT and see how OTs are skillfully tackling the challenges of their profession.Let’s look at some common codes used in Occupational Therapy.

How Spry PT Helps in OT Evaluation?

Spry PT offers a suite of tools and services designed to streamline and enhance the occupational therapy (OT) evaluation process. By integrating advanced technology and comprehensive resources, Spry PT supports therapists in delivering accurate assessments and personalized care plans.

• Integrated Billing: Streamlines the revenue cycle by automating claims submission and patient billing, reducing errors and expediting payment
• Electronic Medical Records (EMR) and Smart Charting: Provides customizable templates and intuitive interfaces for efficient documentation, enabling therapists to focus more on patient care.
• Insurance Eligibility Verification: Automates the verification process, ensuring coverage details are accurate before treatment, thereby minimizing claim denials
• Digital Patient Intake: Allows patients to complete intake forms online, reducing administrative workload and enhancing data accuracy.
• Appointment Scheduling: Offers an integrated scheduler to manage appointments efficiently, reducing no-shows and optimizing clinic operations

Spry PT is an all-in-one solution designed to streamline clinic operations, enhance patient care, and optimize therapy practices' efficiency.

Conclusion

Accurate use of OT evaluation CPT codes is more than just administrative work—it’s essential for effective billing, reimbursement, and ensuring the services you provide are recognized and compensated appropriately. By thoroughly understanding the levels of evaluation complexity (low, moderate, and high) as well as reevaluation codes, you can match each patient’s needs to the correct code, demonstrating the value of your services with precision.

As a medical practitioner, staying up-to-date on these codes helps you avoid common coding errors and streamline documentation, ultimately supporting smoother reimbursement processes. When you accurately code evaluations, you’re not just securing compensation; you’re also reinforcing the quality and clarity of care you deliver. Embracing these coding practices allows you to focus on what truly matters—providing effective, impactful therapy for your patients.

Streamline your practice with SpryPT! Say goodbye to juggling multiple tools. Automate your routine tasks including verifying insurance and securing authorizations with unmatched speed, with SpryPT. From appointments and patient engagement to billing and documentation, SpryPT brings everything together in one seamless platform, simplifying your workflow and saving you valuable time.