Knowledge Base Article

April is National Occupational Therapy month. We at MMP want to acknowledge and thank occupational therapists for their dedication and hard work. According to the American Occupational Therapy Association (AOTA), occupational therapy (OT) is “a vitally important profession that helps people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities.”

There are always new and continuing challenges for OTs in addition to those associated with patient care and 2017 is no different. One of the biggest changes for 2017 is new CPT codes for evaluative services – significantly going from one initial evaluation code to three codes based on the level of complexity of the evaluation. The new codes levels are based on patient history/occupational profile, assessment, and decision making – sounds straight-forward, but a lot more complicated than it appears. First, be aware that all three components must be considered in determining the complexity level of the evaluation as low, moderate, or high. In order to move to a higher level of evaluation all three components must be of the higher level.

Good News

Before we examine the components of the new evaluation codes, there is good news. When the initial 2017 payments rates for the new evaluation/reevaluation codes were released, OTs were shocked to see a decrease in payment rates from last year. CMS has reported there was a technical, computational error in determining the Practice Expense (PE) relative value unit (RVU) for the OT Evaluation and Reevaluation codes. In MLN Matters Article MM9977 April Updates, CMS published new higher weighted PE RVUs that will be retroactive to January 1, 2017 and will result in higher payment rates for the OT evaluation codes once rate corrections are made.

Patient History/Occupational Profile

• In a low level evaluation (CPT 97165), the occupational profile and medical/therapy history include a brief history with review of medical and/or therapy records relating to the presenting problem.
• Moderate level (CPT 97166) includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.
• High level (CPT 97167) includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance.

The key words associated with each level respectively are “brief,” “expanded,” and “extensive.”

The OT considers the patient’s medical and therapy history – what was their prior level of function, their current problem, their goals for treatment – to determine how much review of history is needed to assess the patient and develop a plan of care. These same elements are considered in deciding how complex of an occupational profile is required. Such a profile examines the patient’s occupational history and experiences, patterns of daily living, interests, values, and needs.

Assessment

The assessment level is based on the number of performance deficits identified related to physical, cognitive, or psychosocial skills, and that result in activity limitations and/or participation restrictions. Low complexity (97165) is 1-3 performance deficits, moderate complexity (97166) is 3-5 deficits, and high complexity (97167) is 5 or more deficits.

Performance deficits (activity limitations and/or participation restrictions) are usually identified using standardized assessments. Per the CPT instructions, performance deficits refer to the inability to complete activities due to the lack of skills in one or more of the categories below:

• Physical skills are body structures and functions such as balance, mobility, strength, endurance, fine or gross motor coordination, sensation, dexterity, etc. (AOTA description - motor skills)
• Cognitive skills refer to the ability to attend, perceive, think, understand, problem solve, mentally sequence, learn, and remember. Appropriate cognitive skills allow a person to organize occupational performance in a timely and safe manner. (AOTA description - process skills)
• Psychosocial skills are necessary to successfully and appropriately participate in everyday tasks and social situations. These are influenced by a person’s interpersonal interactions, habits, behaviors, coping strategies, and environmental adaptations. (AOTA description - social interaction skills)

Decision Making

Now comes the hard part where the OT earns their keep, so to speak – taking all of the information from the patient’s history, an analysis of the occupational profile, and the identified performance deficits from the assessment to determine the goals for treatment and develop a plan of care to address those goals. There are a number of factors to consider in the decision making process for occupational therapy.

• Complexity – Overall, how complex is the therapist’s clinical decision making – low complexity (97165), moderate analytic complexity (97166), or high analytic complexity (97167)?
• Assessment data analysis – Was the assessment problem-focused (97165); detailed (97166); or comprehensive (97197)?
• Number of treatment options – Based on the patient’s condition and goals, how many treatment options does the OT consider – only a limited number (97165), several treatment options (97166), or multiple treatment options (97167)?
• Co-morbidities – Does the patient have co-morbidities that affect occupational performance? – No (97165), may have some (97166), or definitely has co-morbidities (97167).
• Assessment modification/assistance – Does the therapist have to provide assistance or make modifications to the assessment(s) to enable the patient to complete the evaluation? Examples could be verbal or physical modifications to directions, task complexity, environment, time, etc. No modifications required (97165), minimal to moderate modification necessary (97166), significant modification required (97167).

Time

You may have noticed that I did not list time as one of the factors to be considered in selecting the evaluation level. That is because time is not a determining factor in selection of the appropriate code. The complexity of the evaluation as described above determines which level of code is selected. Also, the evaluation codes are not time-based codes; one unit of an evaluation code is submitted regardless of the amount of time spent on the evaluation.

Although time is not a factor in determining the code level, the CPT code language provides typical face-to-face times with the patient and/or family for the various code levels. These times are a general guideline about how long each of the levels of evaluation codes might take and to show that higher complexity evaluations take more time than lower complexity evaluations. For OT evaluations the typical times are 30 minutes for low complexity (97165), 45 minutes for moderate complexity (97166) and 60 minutes for high complexity (97167).

Reevaluation Code

The new reevaluation code, CPT 97168, replaces the old code and requires the following 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 intervention and/or goals; and
• A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan or care is required.

Typical time for a reevaluation is 30 minutes of face-to-face time with the patient and/or family.

According to an AOTA article about the new occupational therapy evaluation codes:

“The new descriptions in CPT® set the stage for promoting optimal occupational therapy practice. By conducting a profile, doing standardized and other tests and measures, and showing the breadth of concerns occupational therapy considers, we promote distinct value. The evaluation process can communicate to others the full scope of occupational therapy practice. The codes can be a tool to promote distinct value.”

Occupational Therapy Month is a good time to appreciate the value of OT.