CPT Codes for Occupational Therapy Evaluations

Six years ago, CMS and the AMA decreed that one would become three, and thus, occupational therapy evaluation CPT codes were forever changed into a triad of complexity codes. By now, the not-so-new CPT codes have worked themselves into every EMR, and the terms low, moderate, and high complexity are no less common to rehab therapists than the 8-Minute Rule or adaptive equipment. But, that doesn’t make them any less confusing—particularly for new therapists entering the scene! To help, here’s a handy explainer on CPT codes for occupational therapy evaluations. 

OT Evaluation CPT Codes

Sitting next to its partner in crime, 97001, in the bowels of the AMA CPT dungeon of cast-off codes is 97003—which was replaced with a set of three different evaluative codes that are tiered according to patient complexity. Those codes are:

97165	Occupational therapy evaluation: lowcomplexity
97166	Occupational therapy evaluation:moderate complexity
97167	Occupational therapy evaluation: highcomplexity

The AOTA has pointed to CMS and other payers potentially recognizing the tiered complexities’ value for increased reimbursement, but so far, no such change has occurred. Presently, CMS maintains the work relative value unit (RVU) at 1.54 for all evaluation complexities, and re-evaluations are set at 0.96. In other words, CMS will reimburse the same amount for all three complexities—even if 97163 takes you more than 45 minutes to complete.

(For some background on how RVUs affect the dollar amount you see from Medicare reimbursements, check out this blog post created by our friend, Rick Gawenda. The APTA also has a downloadable calculator for you to check reimbursements by geography, as well.)

Levels of OT Evaluation Complexity

Now, the million-dollar question for any therapy professional affected by these coding updates is: how to classify the complexity of occupational therapy evaluations? We’re glad you asked. To start, all the necessary information can be found in your thorough OT evaluation. From this information, four categories need to be satisfied, with a few sub-categories. They can be found below: 

1. Patient history
   1. Personal factors
      1. Patient age
      2. Education level
      3. Coping style
      4. Social background
      5. Lifestyle
      6. Character
      7. Attitudes
   2. Comorbidities
      1. Past medical history (examples below)
         1. Obesity
         2. Diabetes
         3. Hearing loss
         4. Visual deficits
         5. Cognitive deficits
2. Depth and results of examination and use of standardized tests and measures
   1. Expected progression
   2. Objective findings
3. Clinical presentation
   1. Status of current condition
   2. Mechanism of current condition
4. Clinical decision-making
   1. Goal establishment
   2. Prognosis and probable outcome

Vocabulary

Really quick, before we jump into the defining characteristics of each complexity level, let’s define a few terms that’ll pop up throughout this post:

• Body Regions: Refers to areas of the body, such as head, neck, back, lower extremities, upper extremities, and trunk.
• Body Systems: Includes the circulatory, skeletal, muscular, nervous, respiratory, immune, excretory, integumentary, lymphatic, cardiovascular, reproductive, and digestive systems.
• Body Structures: Refers to the body’s structural or anatomical parts (e.g., organs or limbs), which are classified according to body systems.
• Body Functions: Refers to physiological functions of body systems.

Now, let’s get into the nitty-gritty details associated with each level of evaluation complexity.

97165: Characteristics of a Low Complexity OT Evaluation

Duration	Typically, the OT spends 30 minutes face-to-face with the patient and/or family.
History	The patient’s occupational profile and medical and therapy history includes a brief history with review of medical and/or therapy records related to the presenting problem.
Examination	The OT completes an assessment(s) identifying 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.
Decision-Making	The OT exercises clinical decision-making of low complexity, which includes an analysis ofthe occupational profile, analysis of datafrom problem-focused assessment(s), andconsideration of a limited number oftreatment options. The patient presents withno comorbidities that affect occupationalperformance. Modification of tasks orassistance (e.g., physical or verbal) withassessment(s) is not necessary to enablecompletion of evaluation component.

97166: Characteristics of a Moderate Complexity OT Evaluation

Duration	Typically, the OT spends 45 minutes face-to-face with the patient and/or family.
History	The patient’s occupational profile and medical and therapy history includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.
Examination	The OT completes an assessment(s) identifying 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.
Decision-Making	The OT exercises clinical decision-making of a moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. The 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.

97167: Characteristics of a High Complexity OT Evaluation

Duration	Typically, the OT spends 60 minutes face-to-face with the patient and/or family.
History	The patient’s occupational profile and medical and therapy history includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance.
Examination	The OT completes an assessment(s) identifying 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.
Decision-Making	The OT exercises clinical decision-making of a high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), andconsideration of multiple treatment options. The 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 completion of evaluation components.

OT Reevaluation CPT Codes 

Since we have covered the complexity codes for OT evaluations, we would be remiss to not mention 97168, the OT re-evaluation CPT code that replaced 97004. Luckily, there is no need to tier complexity when coding for a PT re-evaluation. This code is defined as:

• Re-evaluation of occupational therapy established plan of care requiring:
  • An assessment of changes in patient functional or medical status, along with a 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
  • A revised plan of care (a formal re-evaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required)

---

Hopefully this breakdown makes choosing the right level of complexity a little less, well, complex. Remember, clinical judgment plays a huge role in code selection, and your documentation should always clearly support your coding choices. That said, if you’re still scratching your head over the evaluation codes, leave us a question in the comment section below. We’ll do our best to track down an answer.

For more helpful billing FAQs, be sure to check out this blog post.