AMA CPT® Assistant - 2017 Issue 2 (February)
New Occupational Therapy Evaluation Codes (February 2017)
February 2017 pages 3-8 New Occupational Therapy Evaluation Codes The Current Procedural Terminology (CPT®) 2017 code set includes significant revisions to the coding and descriptions for occupational therapy evaluation and re-evaluation services in the Medicine/Physical Medicine and Rehabilitation subsection. Three new codes (97165-97167) were created to describe three levels of occupational therapy evaluation and one code (97168) for re-evaluation. The codes (97003, 97004) that were previously used to report these services were deleted and replaced with these new codes (97165-97168) and extensive guidelines were added. This article provides an overview of these changes. New Codes #97165Occupational therapy evaluation...
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Article Overview
This article explains the 2017 update to occupational therapy evaluation and re-evaluation reporting in CPT. It is intended for occupational therapists, coders, and compliance staff who need to understand the scope of the revised guidance, the documentation elements discussed, and how the changes fit within CPT and related occupational therapy practice references.
Why This Topic Matters
The article matters because it summarizes a significant CPT update affecting how occupational therapy evaluation services are described and documented. It helps readers recognize the overall structure of the revised guidance and the professional sources behind it.
Article Sections
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February 2017 pages 3-8
A short introductory section identifying the publication context for the article.
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New Codes
An overview of the revised occupational therapy evaluation and re-evaluation reporting structure in CPT 2017 and the general purpose of the new guidance.
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Determining the Correct Level of Evaluation
Discussion of the main documentation elements used to support evaluation reporting and the overall approach to selecting a level of service.
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Occupational Profile and (Medical and Therapy) History
General discussion of the history and profile component used in occupational therapy evaluation, including the broad factors considered at different complexity levels.
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Occupational Profile
Coverage of the role of the occupational profile in understanding a patient’s history, habits, needs, and reasons for referral.
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Patient Medical and Therapy History
Discussion of the types of medical and therapy information reviewed as part of the evaluation process.
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Assessments of Occupational Performance
Overview of how occupational performance is assessed and how the evaluation framework relates to identified functional concerns.
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Identification, Assessment, and Determination
Explanation of the general relationship between assessment tools, observation, and documentation within the evaluation process.
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Performance Deficits
Description of the broad categories of performance-related concerns addressed in the article and how they are considered in evaluation.
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Clinical Decision Making
Discussion of the clinical reasoning component used in evaluation reporting and the general factors that influence complexity.
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Assessment
Summary of how the depth of assessment contributes to the evaluation’s complexity level.
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Comorbidities
General discussion of how additional conditions affecting occupational performance factor into evaluation complexity.
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Number of Treatment Options
Overview of how the range of possible intervention approaches is considered when determining complexity.
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Time
Clarification that the reported services are not time-based and that typical face-to-face times are only general guidance.
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Re-evaluation
Overview of the revised guidance for occupational therapy re-evaluation and the components expected when reporting it.
What You Will Learn
- How CPT 2017 revised occupational therapy evaluation and re-evaluation reporting
- What broad documentation components are discussed for occupational therapy evaluation services
- How the article frames complexity in relation to occupational therapy evaluation reporting
- What general factors are considered in occupational therapy re-evaluation guidance
- Which professional organizations and reference sources informed the update
Who Should Read This
- Occupational therapists
- Medical coders
- Coding auditors
- Compliance staff
- Practice managers
Codes Discussed
Code Ranges Discussed
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