Let’s be honest — no therapist got into their career for the billing. But billing insurance providers for services is inseparably bundled with the satisfaction you feel when your patients make progress. And there’s a lot riding on selecting the correct CPT codes for the services you provide. Failing to use the correct billing codes can result in delays or outright denials for payment, holding up reimbursement for therapy that’s already been provided. Even if your claim is accepted, accidentally using the wrong CPT code for a lower level of service than the one you actually provided results in less compensation for your. In fact, Healthcare Business & Technology estimates that poor billing practices cost healthcare providers $125 billion dollars annually. Especially for smaller practices, the health of the business depends on getting accurately reimbursed in a timely manner.
In this post, we’re focusing on OT evaluation codes. We examine the codes associated with the three levels of occupational therapy evaluations, the factors that influence which code to choose, and practical examples of each to help you know which to choose which one. We’ll wrap up by addressing the infamous Modifier 59, examining when and when not to use this often-misunderstood billing code modifier.
The Three Occupational Therapy Evaluation Codes
Occupational therapy evaluations span a broad range of complexity. Knowing whether to code an evaluation as low, moderate, or high complexity can be confusing. The three official billing codes are below. We’ll be examining each in more depth shortly.
- 97165 — Occupational therapy evaluation: low complexity
- 97166 — Occupational therapy evaluation: moderate complexity
- 97167 — Occupational therapy evaluation: high complexity
While a strong dose of professional judgment is required for selecting the right billing code, we’ll provide some helpful guidelines on key differentiators to look for at each complexity level. And we’ll share some examples of what each level of evaluation would look like in practice. By way of reminder, keeping good documentation of what you did is essential for justifying your choice if it’s ever challenged by insurance.
Four Factors Influencing Complexity Levels
There are four primary factors at play in selecting the appropriate complexity level: patient history, examination, clinical presentation, and decision-making. Here’s what to consider in each category.
- Patient history — When you review a patient’s history, you’re looking at a range of factors, including the basics like age, education, lifestyle, and social connections. Patient history also includes an overview of current comorbidities and prior medical and therapy history as it relates to the patient’s presenting problems.
- Evaluation — The evaluation component is exactly as it sounds, an examination of the affected body systems. Standardized measures provide you with the data needed to create a treatment plan, which influence the level of complexity of the evaluation.
- Clinical presentation — Examining a key list of presenting physical signs or symptoms to assist you in understanding a patient’s impairments in a particular body system or systems. If you have a lot to examine and report here, you will choose a higher-level code.
- Decision-making — After reviewing relevant data in the patient’s history, conducting one or more evaluations, assessing clinical presentation, you’ll draw conclusions and make recommendations for care. Again, the more complex the decision-making process and the more recommendations you make, the higher-level of evaluation code you will likely choose.
Examples of What to Look at for Each CPT Code
What should you expect to see at each level? Here are examples that will help guide you in choosing an occupational therapy evaluation CPT code.
On average, a low-complexity exam should last about 30 minutes. You’ll review the patient’s occupational, medical, and therapy histories. In a low-complexity examination, the patient probably won’t display any related health conditions that impact occupational performance. You’ll also conduct standardized assessments to identify one to three performance deficits that are limiting or preventing the patient from participating in one or more life activities. In low-complexity examinations, the patient will be able to complete the assessments without assistance or modifications of tasks. During the decision-making process, you’ll examine the patient’s occupational profile, assessment results, and appropriate treatment options, and the decision-making process won’t be very involved.
A moderate-complexity exam should last around 45 minutes. As with the low-complexity exam, you’ll review the patient’s occupational profile along with their medical and therapy histories. But patients receiving a moderate complexity exam do tend to display health conditions that impact occupational performance. A more thorough review of medical and therapy records will likely be necessary, as they relate to the presenting problem or problems. You’ll also conduct a review of all relevant cognitive, physical, or psychosocial factors as they relate to the presenting problem, and conduct standardized assessments to identify three to five performance deficits that are limiting or preventing the patient from participating in desired life activities. With moderate-complexity exams, the patient should be able to complete the assessments with minimal to moderate assistance or modifications of tasks. The decision-making process will require a bit more work as you formulate several treatment options.
The high complexity exam will last approximately 60 minutes. The therapist conducts a thorough review of the patient’s occupational profile and relevant medical and therapy histories. Physical, cognitive, and psychosocial histories are also reviewed as they relate to their present level of functional performance. Standardized assessments are conducted to identify five or more deficits in performance that result in limitations and/or restrictions. During the assessments, the therapist was required to provide a high degree of assistance or modification in tasks in order to assist the patient in completing the evaluation. The resulting analysis of the patient’s history, assessment results, and multiple treatment options requires a high degree of analytical complexity.
For many occupational therapists, Modifier 59 is a well-known but poorly-understood billing code modifier. By design, Modifier 59 is designed for use in insurance billing only as a last resort if other options aren’t applicable. Here are three situations where you would use Modifier 59.
- Billing for services that aren’t usually performed at the same time — If you performed two separate services in the same day that aren’t usually done together, Modifier 59 allows you to bill for two distinct services.
- Billing codes that are linked pairs — When using two codes that are considered a linked pair, you’ll only be reimbursed for one of the two services unless you use the Modifier 59 code to indicate that you provided both services independently from each other. If that’s the case, affixing this modifier will result in being reimbursed for each service individually.
- A truly last resort — If there’s another code that describes the services provided equally well, use that one instead. Modifier 59 is strictly for use when there’s just no better way to describe how services were provided.
Having a solid understanding of which level occupational therapy examination code to choose will allow you to confidently bill payers and be reimbursed the full amount that you should be. And, in turn, being quickly and fully reimbursed will help you grow your practice and help even more patients.
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