2017 New Occupational Therapy Evaluation Coding Overview | www.mspinkymaniri.com | 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

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 history
2. Assessments of occupational performance
3. Medical decision making
4. 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 performance
Levels of Assessment of Occupational
Performance:
● Low Complexity (Problem-Focused)
● Moderate Complexity (Detailed)
● High Complexity (Comprehensive)

2.1 CPT® Definition of Performance Deficits
Performance 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
● 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
● 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-
EVALUATION
CPT 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=/thera
pyservices
● https://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/Downloads/R3654CP.pdf

2017 New Occupational Therapy Evaluation Coding Overview | www.mspinkymaniri.com | Medical Practice Consultant

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2017 New Occupational Therapy Evaluation Coding Overview | www.mspinkymaniri.com | Medical Practice Consultant