Occupational therapy evaluation, moderate complexity, requiring these components:
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Occupational therapy evaluation, as defined by CPT® Code 97166, involves a comprehensive assessment of a patient's functional abilities and challenges. This evaluation is characterized by moderate complexity, which necessitates a thorough understanding of the patient's occupational profile and medical history. The occupational therapist conducts an extensive review of the patient's medical and therapy records, alongside an in-depth examination of physical, cognitive, or psychosocial factors that may influence the patient's current functional performance. The evaluation aims to identify specific performance deficits—typically ranging from three to five—that contribute to limitations in daily activities and participation in various life roles. These deficits may relate to physical capabilities, cognitive functions, or psychosocial interactions. The clinical decision-making process during this evaluation is of moderate analytic complexity, requiring the therapist to analyze the occupational profile and detailed assessment data while considering multiple treatment options. It is important to note that patients may present with comorbidities that can impact their occupational performance, necessitating a tailored approach to their evaluation. The occupational therapist may need to provide minimal to moderate modifications or assistance, whether physical or verbal, to facilitate the patient's completion of the evaluation components. Typically, this evaluation process involves approximately 45 minutes of face-to-face interaction with the patient and/or their family, ensuring a comprehensive understanding of the patient's needs and challenges in achieving independent functioning and enhancing overall health and well-being.
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The occupational therapy evaluation (CPT® Code 97166) is indicated for patients who require a comprehensive assessment of their functional abilities and limitations. This evaluation is particularly relevant for individuals experiencing:
The procedure for conducting an occupational therapy evaluation of moderate complexity involves several key steps:
After the occupational therapy evaluation, the therapist will develop a treatment plan based on the findings from the assessment. This plan will address the identified performance deficits and outline specific interventions aimed at improving the patient's functional abilities. The therapist may also schedule follow-up appointments to monitor the patient's progress and make necessary adjustments to the treatment plan. In cases of re-evaluation, an interim history will be taken to assess the patient's response to previous treatments, and the plan of care will be revised accordingly, considering any changes in the patient's functional and medical status or environmental factors that may influence future interventions or goals.
| Short Descr | OT EVAL MOD COMPLEX 45 MIN | Medium Descr | OCCUPATIONAL THERAPY EVAL MOD COMPLEX 45 MINS | Long Descr | 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 (ie, 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 (eg, 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. | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 7 - Physical Therapy Service, for which Payment may not be Made | Multiple Procedures (51) | 5 - Special payment adjustment rules on the RVU practice expense component of multiple therapy service applies... | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Service Paid under Fee Schedule or Payment System other than OPPS | Type of Service (TOS) | 1 - Medical Care | Berenson-Eggers TOS (BETOS) | M5D - Specialist - other | MUE | 1 |
| GO | Services delivered under an outpatient occupational therapy plan of care | KX | Requirements specified in the medical policy have been met | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 95 | Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system. | GW | Service not related to the hospice patient's terminal condition | GA | Waiver of liability statement issued as required by payer policy, individual case | 97 | Rehabilitative services: when a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified health care professional may add modifier 97 to the service or procedure code to indicate that the service or procedure provided was a rehabilitative service. rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt, or disabled. | CO | Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant | CR | Catastrophe/disaster related | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | 96 | Habilitative services: when a service or procedure that may be either habilitative or rehabilitative in nature is provided for habilitative purposes, the physician or other qualified health care professional may add modifier 96 to the service or procedure code to indicate that the service or procedure provided was a habilitative service. habilitative services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep and/or improve those learned skills. habilitative services also help an individual keep, learn, or improve skills and functioning for daily living. | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | AJ | Clinical social worker | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | GP | Services delivered under an outpatient physical therapy plan of care | GT | Via interactive audio and video telecommunication systems | GZ | Item or service expected to be denied as not reasonable and necessary | HN | Bachelors degree level | HP | Doctoral level | KC | Replacement of special power wheelchair interface | LT | Left side (used to identify procedures performed on the left side of the body) | PO | Excepted service provided at an off-campus, outpatient, provider-based department of a hospital | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | Q5 | Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | RT | Right side (used to identify procedures performed on the right side of the body) | U5 | Medicaid level of care 5, as defined by each state | U8 | Medicaid level of care 8, as defined by each state | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2017-01-01 | Added | Added |
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