Neurology & Pain Management Coding Alert

Question: When one of our providers performs occupational therapy, how should I report the service?

Illinois Subscriber

Answer: It depends on the type and level of occupational therapy.

Use these codes for initial occupational therapy visits, depending on encounter specifics:

• 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 (ie, 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 …
• 97166 — … 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 …
• 97167 — … 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 … .

Remember: Regardless of the occupational therapy code you choose, you cannot report occupational therapy unless, according to CPT^® 2019, the encounter includes the following components:

• “Occupational profile and client history (medical and therapy)
• “Assessments of occupational performance
• “Clinical decision making
• “Development of plan of care.”

Exception: If the cognitive therapy session is a reevaluation for a plan of care that your provider already put in place, you’ll probably report 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 …).