Occupational therapy (OT) helps millions of individuals worldwide, especially those with chronic diseases and those recovering from injuries. The primary purpose of OT is to help individuals improve functional independence and participation in daily activities.
OT services address physical, cognitive, sensory, and environmental factors to improve participation in daily activities. However, from a billing perspective, OT is one of the most frequently billed services in medical care.
Billing professionals use CPT code 97165 to bill a low-complexity evaluation for occupational therapy services. But its billing is not as straightforward as it may seem. It requires careful patient assessment and coding considerations.
In this article, let’s discuss how to bill 97165 accurately.
CPT Code 97165 – Description
CPT code 97165 falls under the Occupational Therapy Evaluation CPT code set, four CPT codes in total: 97165-97168. The official descriptor for 97165 explains:
“Occupational therapy evaluation, low-complexity decision-making, requiring the following components:
- An occupational profile and medical and therapy history.
- Assessment(s) of occupational performance deficits.
- Development of a plan of care.
CPT 97165 often involves approximately 30 minutes of evaluation time. However, code selection is based on the evaluation’s complexity level, not time.
Breaking Down the Three Required Components
The key elements to consider when billing CPT code 97165:
1. Occupational Profile and Medical/Therapy History
The CPT code requires the patient’s medical history and therapy records related to the current medical problem. Similarly, the occupational profile records the patient’s:
- Roles
- Needs
- Daily habits
- Routines
- Values
All of this information is required to establish a clinical context for the following medical assessment.
2. Assessment of Performance Deficits
The therapist conducts tests and collects clinical observations to identify relevant performance deficits in occupational function. These deficits can be in the following domains, which may result in participation restrictions or activity limitations:
- Physical
- Psychosocial
- Cognitive
The documented evaluation complexity helps determine the appropriate code selection.
3. Low-Complexity Clinical Decision-Making
Once the occupational profile and assessment data are analyzed, the therapist uses the collected information to establish a low-complexity clinical decision-making process.
The evaluation complexity depends on the documented clinical decision-making requirements. Similarly, the occupational performance assessment is just as crucial.
Understanding the Code Selection Criteria
CPT code 97165 is reported when the evaluation meets the low-complexity criteria. However, if the evaluation indicates moderate complexity, CPT 97166 should be reported.
Additionally, comorbidities affecting occupational performance are considered when determining the appropriate evaluation complexity.
Scenarios Where CPT Code 97165 is Applicable
Billing CPT code 97165 can be challenging unless the billing teams understand its applications. Typically, billing professionals make errors because of the components relevant to the code.
Therefore, the following scenarios comprehensively discuss three cases where the CPT code is applicable:
Post-Stroke Rehabilitation
Imagine a 72-year-old female patient who recently experienced a mild ischemic stroke without any significant residual complications. She complains of slight weakness in her right hand and mild difficulty with motor tasks like buttoning clothes. However, she explains that she can independently perform most daily activities and has no cognitive, sensory, or coordination deficits.
As a result, she is referred to an occupational therapist for an initial evaluation. During the visit, the therapist completes the patient’s occupational profile and evaluates her:
- Grip strength and fine motor control of the right hand
- Ability to perform one self-care task (e.g., fastening buttons and zippers)
After the evaluation, the therapist notices a mild, isolated functional limitation in fine motor dexterity affecting one activity of daily living. The patient has no other comorbidities affecting occupational performance, and her overall function is otherwise intact. Given the limited number of performance deficits (one) and the straightforward nature of the clinical presentation, the therapist determines this requires low-complexity clinical decision-making. Therefore, he creates a simple home-exercise program focused on fine motor and grip strengthening, along with adaptive strategies for dressing.
Here, CPT code 97165 can be reported for the occupational therapy evaluation supported by documented low-complexity medical decision-making.
Workplace Injury Evaluation
Imagine a 45-year-old male employee who develops reduced hand function and wrist pain due to repetitive job duties. He is referred for occupational therapy for an initial evaluation.
During the evaluation, the patient’s work-related activities are evaluated. The occupational therapist also determines the following:
- Range of motion
- Strength
- Pain impact
- Ability to fulfill tasks
However, the only functional deficit identified was reduced grip strength, affecting the ability to grip tools.
After the evaluation, the therapist establishes a treatment plan addressing the patient’s functional limitation. In this case, since the number of performance deficits was one, there were no comorbidities, and the session required low-complexity level medical decision-making, it can be billed under CPT code 97165.
Pediatric Developmental Evaluation
Consider the case of a 6-year-old male child with a diagnosed developmental delay. He is referred to an occupational therapist for evaluation. The child faces difficulty with:
- Dressing
- Handwriting
- Age-appropriate play activities
Therefore, an occupational profile is gathered from the parent, and fine motor coordination is assessed. Moreover, the child is evaluated for functional participation in home and school activities, with documented findings supporting low-complexity evaluation criteria.
The therapist identifies limitations in daily function and formulates a plan to improve the child’s independence in daily activities. Afterwards, the billing team used CPT code 97165, as three discrete performance deficits were identified and documented without any comorbidities, and it resulted in low-complexity level medical decision-making.
When CPT Code 97165 Does Not Apply
While 97165 can be used to bill payers for initial evaluations, the code has its limitations. Reporting the CPT code at the wrong time can become a significant billing compliance risk.
As mentioned earlier, CPT code 97165 can only be used when the documentation supports low-complexity decision-making. If the evaluation indicates moderate complexity, 97166 should be used. The following cases may also be accurately billed using 97166 if:
- The evaluation meets moderate-complexity criteria based on documented clinical decision-making and occupational performance findings.
- Evaluation findings require moderate-complexity clinical decision-making.
- Comorbid conditions (such as hypertension, diabetes, or depression) impact daily functional performance.
- Moderate-complexity clinical decision-making is used by the therapist, involving multiple treatment options, potential risks, or changing patient needs.
Applicable Modifiers for CPT Code 97165
Submitting CPT code 97165 claims without proper modifier use can be a serious billing violation. It may put your claim at risk and result in a delay, denial, or recoupment. The following modifiers apply to the CPT code:
| Modifier | What It Indicates |
|---|---|
| GO | Indicates initial evaluation services provided under an outpatient occupational therapy plan of care. |
| 59 | Reports a distinct procedural service rendered on the same day as the initial evaluation (subject to payer policy). |
Source: AOTA
Note: Modifier GO is required when reporting Medicare outpatient occupational therapy services provided under an OT plan of care. However, modifier 59 may not be routinely reported with CPT 97165. Specific alternatives to modifier 59 (XE / XP / XS / XU) may be appended to the claim under certain circumstances.
CPT Code 97165 – Billing & Reimbursement Guidelines
Billing errors can occur if practices do not understand the reimbursement guidelines applicable to the CPT code 97165. Here’s a comprehensive breakdown of the most crucial guidelines to remember:
- Medicare covers occupational therapy services and low-complexity evaluations when medically necessary. However, payment and coverage require accurate documentation.
- Private insurance plans may vary for payers. Therefore, always review if additional documentation, such as prior authorization, is required.
- Medicare payments for CPT 97165 might vary based on geographical location.
- Medicare may have certain limits on therapy services, session restrictions, or annual caps.
- Billing teams must prove medical necessity and justify occupational therapy services for reimbursement.
Documentation Requirements
CPT code 97165 cannot be billed for reimbursement without complete documentation. The claim should include the following documentation:
Occupational Profile and History
The patient’s presenting problem, therapy, medical records, and relevant background documents should be added to the claim. Plainly stating “refer patient to OT” is insufficient.
The therapist must establish a proper link between the patient’s personal context and the presenting occupational concerns.
Type and Impact of Occupational Performance Deficits
The deficits cannot be documented with a general term such as “multiple deficits”. Each deficit should be documented explicitly, along with the corresponding domain.
Assessment Tool and Finding
Each standardized assessment performed should be documented and listed in the evaluation record (e.g., AMPS, Purdue Pegboard, Jebsen–Taylor).
Billing teams must also include scored findings because an observation without a named tool does not reliably support the evaluation.
Comorbidities and their Occupational Function
If comorbidities are present, documentation should clarify whether they affect occupational performance and evaluation complexity. If comorbidities affect occupational performance and increase evaluation complexity, a higher-complexity code may be appropriate.
Append Modifier GO on the Claim
Modifier GO may be required for applicable Medicare OT claims. Additionally, documentation should identify the treating provider and comply with applicable supervision and billing requirements.
Treatment Plan and Clinical Decision-Making
The billing team must always document the treatment approach selected, along with the specific goals. The treatment plan should include measurable goals, intervention strategies, and expected outcomes (subject to applicable payer requirements).
CPT Code 97165 in a Nutshell
CPT code 97165 indicates an initial occupational therapy evaluation involving low-complexity medical decision-making. The CPT code may seem simple conceptually, but its execution can present serious challenges from a billing perspective.
Billing teams should remain mindful of the latest billing and coding guidelines discussed above. However, if your in-house staff continues to struggle with billing, you may require professional assistance.
MediBillMD’s medical billing services prevent billing errors and ensure your practice faces no revenue bottlenecks.
