Occupational therapy evaluation, high complexity, requiring these components:
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Occupational therapy evaluation, high complexity, is a comprehensive assessment process designed to evaluate a patient's functional abilities and limitations. This evaluation is crucial for developing a tailored treatment plan that addresses the specific needs of the patient. The procedure begins with the collection of an occupational profile and a thorough medical and therapy history, which involves reviewing existing medical and therapy records. Additionally, there is an extensive examination of the patient's physical, cognitive, and psychosocial history, all of which are pertinent to understanding their current functional performance. The occupational therapist identifies five or more performance deficits that may relate to physical, cognitive, or psychosocial skills, which can lead to activity limitations or participation restrictions in daily life. The evaluation process also requires high-level clinical decision-making, characterized by the analysis of the patient profile and data derived from comprehensive assessments. This analysis takes into account the patient's comorbidities, which can significantly impact their occupational performance. The complexity of the evaluation is further heightened by the necessity for significant modifications of tasks or assistance, whether physical or verbal, to enable the patient to complete the evaluation components effectively. Typically, this evaluation process involves approximately 60 minutes of face-to-face interaction with the patient and/or their family, ensuring a thorough understanding of the patient's needs and circumstances.
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The occupational therapy evaluation, high complexity, is indicated for patients who present with a variety of conditions that may affect their ability to perform daily activities independently. The following are specific indications for this procedure:
The procedure for conducting a high complexity occupational therapy evaluation involves several detailed steps:
After the high complexity occupational therapy evaluation, the occupational therapist will analyze the collected data and develop a comprehensive treatment plan tailored to the patient's specific needs. This plan may include recommendations for therapy interventions, adaptive equipment, and strategies to overcome identified barriers in the patient's environment. The therapist will also schedule follow-up appointments to monitor the patient's progress and make necessary adjustments to the treatment plan based on the patient's response to therapy and any changes in their condition or environment. Continuous evaluation and re-evaluation are essential to ensure that the treatment remains effective and aligned with the patient's goals for independent functioning.
| Short Descr | OT EVAL HIGH COMPLEX 60 MIN | Medium Descr | OCCUPATIONAL THERAPY EVAL HIGH COMPLEX 60 MINS | Long Descr | 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 identifies 5 or more performance deficits (ie, 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 (eg, 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. | 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 | 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. | 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. | FR | The supervising practitioner was present through two-way, audio/video communication technology | 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. | GW | Service not related to the hospice patient's terminal condition | 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. | 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. | 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. | AK | Non participating physician | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CO | Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant | CR | Catastrophe/disaster related | F9 | Right hand, fifth digit | GA | Waiver of liability statement issued as required by payer policy, individual case | GP | Services delivered under an outpatient physical therapy plan of care | GT | Via interactive audio and video telecommunication systems | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | 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 | GZ | Item or service expected to be denied as not reasonable and necessary | KY | Dmepos item subject to dmepos competitive bidding program number 5 | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | RT | Right side (used to identify procedures performed on the right side of the body) | U8 | Medicaid level of care 8, as defined by each state | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2017-01-01 | Added | Added |
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