Top CPT codes for Occupational Therapy Evaluation

Introduction to current procedural terminology (CPT) codes

Current procedural terminology (CPT) codes are used during the healthcare billing process. For every single task that an occupational therapist completes during a client session, there is a corresponding CPT code that often considers the patient's medical and therapy history. CPT codes were developed by the American Medical Association (AMA), and they continue to assess and alter these codes in response to the development of new medical treatments. After claims have been lodged with insurance providers, the CPT codes will be assessed, and reimbursement will reflect the treatments administered.

As such, it is absolutely essential that occupational therapists and other clinicians are aware of what CPT codes should be used and ensure they double (and triple) check these before submitting a claim. We understand that staying on top of CPT codes can be a pretty extensive task, which is why we've written this guide outlining the top CPT codes for occupational therapists. Using this information, you'll be able to ensure you're creating effective bills, allowing your practice to receive accurate reimbursement at a much faster rate.

CPT coding guide for occupational therapy

CPT codes are five-digit numbers that indicate specific treatments delivered to patients. Occupational therapy treatment codes are typically measured in 15-minute increments, meaning the services you deliver will be billed according to these time units. As I'm sure you know, the underlying incentive of occupational therapy is to guide clients toward goals they hope to achieve. The specific treatments employed to ensure this unsurprisingly vary quite significantly. As such, it is important that you consider the end goal, or treatment outcome, intended for each of your therapeutic interventions.

Treatment CPT codes for occupational therapy

Although the specific treatments you use as an occupational therapist will vary depending on your clients and their needs, it can help to have an understanding of the most commonly used CPT codes. If you are aware of each of these, the process of submitting accurate claims will be significantly easier. 

• CPT code 97110: Therapeutic procedure for one or more areas. Each procedure is 15 minutes. This includes therapeutic exercises to develop strength and endurance, range of motion, and flexibility.
• CPT code 97113: Aquatic therapy with therapeutic exercises.
• CPT code 97112: This is for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.
• CPT code 97116: Gait training, also including stair climbing.
• CPT code 97535: Self-care and/or home-management training. This includes activities of daily living (ADLs) and compensatory training, meal preparation, safety procedures, etc.
• CPT code 97140: Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes).
• CPT code 97124: Massage treatments.
• CPT code 97129: Therapeutic interventions targeting cognitive function and compensatory strategies to manage the performance of an activity. Direct patient contact, initial 15 minutes.
• CPT code 97150: Therapeutic procedure for a group (2 or more people). It is important to note that group procedures are not based on time and need to be recorded for each group member.

• CPT code 97542: Wheelchair management  (e.g., assessment, fitting, training), each 15 minutes.
• CPT code 97537: Community/work reintegration training, direct one-on-one contact, each 15 minutes.

Although this is not an exhaustive list of every CPT code that applies to occupational therapy, it includes some of the most commonly used. As I'm sure you'll find, the more practice you have using these codes, the more easily you'll remember them. Regardless of how efficient you become at recording your treatment codes, it's always a good idea to double-check their accuracy before submitting your claims.

What is included in an occupational therapy evaluation?

Occupational therapy evaluations are conducted with patients at different times. They help identify the client's current abilities and limitations, their past medical history, and their goals. When conducting an occupational therapy evaluation, the following four areas must be included:

Occupational profile

The occupational profile refers to the unique evaluation of the specific patient's experiences and relevant history. It includes comments on their day-to-day life, needs, wants, and more general interests that affect occupational performance. The occupational profile should be completed by both the therapist and the client/client's family.

Patient history

The patient history involves the patient's medical and treatment history. This information should be in the patient's medical record, which you should have access to. 

Clinical decision making

Clinical decision-making refers to the therapeutic intervention, outlining how the therapist will guide the client toward achieving their desired goals and outcomes in their everyday life.

Development of a plan of care

Finally, the plan of care assesses whether goals are being met and ensures the treatment plan is being altered to improve functional performance. It also ensures that the treatment plan is being altered when/where appropriate.

Top CPT codes for occupational therapy evaluation

The CPT codes used for occupational therapy evaluations differ slightly from the codes used for treatment methods. Currently, three types of evaluation codes are used. These correspond to the complexity of the evaluation's outcome. For example, if a patient has 1-3 performance deficits, a small number of treatment options, and a brief medical history, then the complexity of their evaluation would be low. 

On the other hand, if a patient has 5+ performance deficits, a detailed and extensive medical history, and the possibility of numerous treatment interventions, then the complexity of their evaluation would be high. These are the CPT codes that you should use for occupation therapy evaluations:

• CPT code 97165: Occupational therapy evaluation, low complexity
• CPT code 97166: Occupational therapy evaluation, moderate complexity
• CPT code: 97167: Occupational therapy evaluation, high complexity ‍
• CPT code 97168: Occupational therapy re-evaluation

Conclusion

Figuring out the best way to accurately record CPT codes is an integral component of working as an occupational therapist. Having a solid understanding of the most commonly used codes will be sure to save you time when it comes to recording patient notes. With the development of healthcare technology, new systems are available that can assist with the production and organization of medical billing and coding. If this is something you are interested in, we highly recommend checking Carepatron – an all-in-one practice management software designed to automate various processes for healthcare businesses.