Evaluation Codes for Occupational Therapy Billing

Occupational therapy evaluation codes are divided into three tiers based on complexity: low, moderate, and high. The complexity level of an evaluation is based on three areas: the patient’s profile and history, the assessment of occupational performance, and level of clinical decision making exercised by the occupational therapist during the evaluation. While this categorization seems straightforward, it can be challenging to know what constitutes low complexity, moderate complexity, and high complexity. In this post, we’ll walk through what to look for at each level to help you discern which CPT evaluation code best matches the service you performed. We’ll also cover the code for an occupational therapy reevaluation and its criteria. As we close out, we’ll look at three mistakes commonly made with occupational therapy evaluation billing codes.

What to Consider as You’re Choosing Evaluation Codes for Occupational Therapy

As we discuss each evaluation code, we’ll begin with the exact verbiage from the CPT Code Manual. From there, we’ll share practical markers to look for at each level of complexity. It’s important to note that to select the correct level of complexity, you must be sure all three areas meet the criteria for that evaluation level. For example, if an evaluation met the definition of a low level of complexity for both profile and history and assessment of occupational performance components, but the level of clinical decision-making was done at a moderate level, you would still be required to bill at a low level of complexity. 

Low Complexity Evaluation (OT 97165)

A low complexity evaluation takes the least amount of time and involves a relatively uncomplicated process of reviewing, evaluating, and creating a plan of care. Here’s the exact definition as found in the CPT Code Manual.

 

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.

Defining Characteristics of a Low Complexity Evaluation

Determining the correct type of occupational therapy evaluation requires sound professional judgment. While there’s no one-size-fits-all definition of what constitutes a low complexity evaluation, here’s a description you can judge by.

 

A low complexity evaluation begins with a brief review of the patient’s medical and/or therapy records related to the presenting problems. There are no comorbidities that impact the presenting problem. In this evaluation, you would use standardized assessments to identify up to three deficits in functional performance that result in the patient’s activities or participation being limited or restricted. The patient does not require modifications or assistance to complete the assessments. Performance deficits may be in the physical, cognitive, or psychosocial areas. When considering your menu of treatment options, you would include an analysis of the occupational profile and data from problem-driven assessments. A low level of analytical skills is required during this type of evaluation. 

Moderate Complexity Evaluation (OT 97166)

An occupational therapy evaluation of moderate complexity is a mid-tier evaluation. According to the CPT Code Manual, an evaluation of moderate complexity needs to include the following characteristics. 

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.

Defining Characteristics of a Moderate Complexity Evaluation

During a moderate complexity evaluation, you would begin with a more in-depth review of the patient’s medical and/or therapy records. You would also complete a secondary review of the patient’s relevant physical, cognitive, and psychosocial history. The patient may have comorbidities affecting their occupational performance. Using standardized assessments, you would identify three to five deficits in the areas of physical, cognitive, or psychosocial ability. The patient may require minor to moderate modifications or assistance when completing the assessments. Performance deficits may be in the physical, cognitive, or psychosocial areas. You may develop an expanded range of treatment options using the occupational profile and data from problem-driven assessments. Analytical skills are exercised at a moderate level.

High Complexity Evaluation (OT 97167)

An evaluation at the highest level of complexity is typically done with a patient exhibiting multiple impairments and complex medical history. The CPT Code Manual states an evaluation of high complexity must satisfy each of the criteria listed below.

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 identify 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • A clinical decision-making is 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.

Defining Characteristics of a High Complexity Evaluation

During a high complexity evaluation, you would conduct an in-depth review of the patient’s medical and/or therapy records, including a thorough review of the patient’s relevant physical, cognitive, and psychosocial history. The patient has comorbidities that are impacting occupational performance. Using standardized assessments, you would identify five or more physical, cognitive, or psychosocial performance deficits. The patient requires a significant level of modifications or assistance to complete the assessments. Performance deficits may be in the physical, cognitive, or psychosocial areas. Extensive data from various sources, including the patient’s occupational profile and a range of problem-focused assessments, requires a high level of analytical skills to develop several treatment options.

Reevaluation (OT 97168)

Unlike the three-tiered system of occupational therapy evaluation codes, the reevaluation is just a single code. Compared with the evaluation codes, the criteria found in the CPT Code Manual are relatively simple.

Reevaluation 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.

Defining Characteristics of a Reevaluation

The reevaluation isn’t broken down into levels of complexity like the evaluations are. A reevaluation is typically conducted when there is a new clinical finding, a substantial change in the patient’s functioning, or when the patient is not responding to the current therapeutic interventions. 

Common Mistakes with Occupational Therapy Evaluation Coding

When billing for occupational therapy evaluations, it’s easy to make mistakes. Incorrectly coding the complexity level of an evaluation can result in your claim being denied, and having to make the necessary corrections and resubmit the claim wastes time and can delay your reimbursements. So you’ll want to avoid mistakes when possible. Here are three of the most frequently made occupational therapy billing mistakes.

  • Undercoding — If you’re not thoroughly familiar with the criteria for each level of occupational therapy evaluation, you may inadvertently be undercharging for services you’ve performed. Knowingly undercoding isn’t a way to protect your practice from audits, and it’s actually considered unethical.
  • Overcoding — On the flip side, overcoding puts you at risk of an insurer denying your claim if the level of evaluation you’re claiming seems excessive. Remember, each of the three main areas of the evaluation must meet the criteria for the highest level of evaluation you’re claiming.
  • Incomplete Documentation — If an insurer challenges one of your billing claims or if your practice is audited, having documentation to back up the level of service you’re claiming is essential. Your therapy notes must be able to objectively prove that you provided the service you’re billing for.

In Conclusion

Billing an insurer for a higher level of complexity than your documentation can support may result in a billing claim being rejected. Choosing a code that’s at a lower complexity than you actually performed will result in being underpaid for your services. By understanding the CPT code descriptions, you’ll be able to bill with confidence, knowing you’re getting properly compensated and can back up your claim with sound reasoning.

Check out our Complete Guide to Occupational Therapy Billing to learn more about how to simplify and improve your billing processes.

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