If you are in the World of occupational therapy, you know that evaluations are the first step to understanding a patient’s needs. But things can get tricky when it comes to medical billing services‘ evaluations. You must use the right CPT codes to ensure proper reimbursement while complying with everything.
Understanding occupational therapy CPT codes for psych evaluation is the key to therapists, billers, and administrators. An easy mistake whether it’s in choosing the wrong code or inability to support why it is chosen can be disastrous in a variety of ways; it might be claim denial, delayed payments, or compliance.
Let’s take these occupational therapy evaluation CPT codes and make them breakable so that you can be busy doing what matters – restoring independence for your patients.
CPT codes represent the standardized codes for describing medical services and procedures. In occupational therapy, the evaluation codes determine the complexity level for an assessment and the level of a patient’s need as their report is documented regarding billing.
Three main CPT codes for occupational therapy evaluations and one are used for re-evaluations:
97165 – Low Complexity Occupational Therapy Evaluation
97166 – Moderate Complexity Occupational Therapy Evaluation
97167 – High Complexity Occupational Therapy Evaluation
97168 – Occupational Therapy Re-Evaluation
Each of these codes indicates another level of assessment, and it is important to choose the appropriate one that best suits the diagnosis of the patient.
Breaking Down Evaluation Codes
1. 97165 – Low Complexity Evaluation
This code applies when the occupational therapist evaluates a relatively simple case.
Low-complexity evaluation entails the following:
- A short history of the patient’s condition with minimal medicine or therapy history.
- 1-3 performance deficits impacting activities.
- No substantial changes in the assessment.
Example: A patient with a partial wrist sprain who requires simple compensatory techniques for activities
.
2. 97166 – Moderate Complexity Assessment
This code is assigned when the assessment involves more comprehensive information and additional clinical judgment.
A moderate complexity assessment includes:
- More extensive medical and therapy history.
- 3-5 performance deficits that impact functions.
- Minimal to moderate alterations when conducting the assessment.
Example: A stroke patient who can only barely achieve adequate grip strength and hand coordination to complete minimal self-care.
3. 97167 – High Complexity Evaluation
It is applied to a patient who is significantly impaired. This calls for an intensive examination.
A high-complexity evaluation would most likely comprise the following:
- In-depth medical and therapy history.
- 5 or more performance deficits, which impair his ability to complete his activities.
- Significant changes to the assessment process are needed.
Example: A patient with TBI, requires a comprehensive evaluation of motor abilities, cognitive functioning, and sensory integration.
4. 97168 – Occupational Therapy Re-Evaluation
Re-evaluation is indicated when:
- There has been an important change in the patient’s condition.
- Goals need to be revised based on improvement or deterioration.
- Further information is needed to update the treatment plan.
Example: A postoperative shoulder surgery patient who seemed to be progressing well but has now developed unexplained limitations to mobility.
Choosing the Right CPT Code
The choice of occupational therapy CPT codes will depend on how complex the case is and the amount of time and effort used in the assessment.
To determine which code is right, ask yourself:
- How many performance deficits does the patient have?
- How complex is their medical history?
- Is the evaluation modified or revised?
- Is this a new evaluation, or a re-evaluation?
By paying attention to these considerations, you can minimize claims denials and maximize reimbursement accuracy.
Common Errors in Billing with Occupational Therapy CPT Codes
Even seasoned therapists and billers can make mistakes when using occupational therapy CPT codes. Some common errors to be aware of include:
- Wrong complexity level – Do not code for a high-complexity evaluation when the case is only moderate. Insurers look at documentation carefully!
- Failure to document performance deficits – Always include clear, measurable data to support the level of evaluation.
- Missing justification for a re-evaluation – A 97168 claim must explain why a re-evaluation is needed, such as a change in condition.
- Not verifying payer policies – Some insurance companies have specific documentation requirements, so always double-check guidelines before submitting claims.
Avoiding these mistakes ensures faster approvals and smoother billing processes.
Why Proper CPT Coding Matters
Accurate CPT coding isn’t just about getting reimbursed quickly—it’s also about maintaining compliance and transparency in healthcare. Using the right codes:
- Ensures proper payment for the level of service provided.
- Help in avoiding claim rejections that delay payments.
- Protects against audits and compliance risks.
- Helps track patient progress through correct documentation of evaluations.
Mastering occupational therapy CPT codes helps practices optimize revenue cycles, be more efficient, and ensure quality patient care.
Conclusion
The use of the right occupational therapy CPT codes in evaluation is fundamentally important for proper billing, payment, and flow in the process. There is a simple case with low complexity or a complex case with extensive detail to the highly complex case for evaluation. Selecting the right code makes all the difference.
Understanding the difference between 97165, 97166, 97167, and 97168 can help reduce denials, ensure accuracy in claims, and, ultimately improve patient care.
If your practice will streamline billing without medical coding service errors, then keeping in touch with all the best CPT coding practices is the solution. When it is smooth billings, therapy can focus its attention on patients’ real rehabilitation needs.
