2025 CPT code 97166
(Active) Effective Date: N/A Medicine - Physical Medicine and Rehabilitation Feed
Occupational therapy evaluation, moderate complexity.
Modifiers may be applicable in specific circumstances (e.g., to indicate telehealth services or distinct procedural services).
Medical necessity must be established for the occupational therapy evaluation. The evaluation is considered medically necessary when the patient exhibits functional deficits related to a medical condition, illness, or injury. The evaluation must be performed to determine the appropriate treatment plan to address these deficits.Payer-specific guidelines should always be consulted.
The occupational therapist is responsible for conducting the evaluation, interpreting the findings, and developing the treatment plan.
In simple words: An occupational therapist performs a moderately complex evaluation to assess a patient's ability to perform daily activities. This involves reviewing medical history, assessing 3-5 areas of difficulty, and considering treatment options.It typically takes about 45 minutes.
Occupational therapy evaluation, moderate complexity, requiring these components:1. 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.2. An assessment(s) that identifies 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.3. 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.*Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family.
Example 1: A patient with a recent stroke has difficulty dressing and bathing. The OT performs a moderate complexity evaluation to assess their physical and cognitive deficits and develop a treatment plan to improve their independence with these activities., A child with autism has difficulty with social skills and sensory processing. The OT performs a moderate complexity evaluation to identify specific deficits and develop a treatment plan to improve their participation in school and social activities., An individual with carpal tunnel syndrome experiences pain and weakness in their hand. The OT performs a moderate complexity evaluation to assess their functional limitations and develop a treatment plan that may include splinting, exercises, and adaptive strategies.
Documentation should include the occupational profile, medical and therapy history, results of the assessments performed (identifying 3-5 performance deficits), the clinical decision-making process, and the developed treatment plan. The documentation should support the medical necessity of the evaluation and the level of complexity.
- Revenue Code: M1A - OFFICE VISITS - NEW
- Specialties:Occupational Therapy, Physical Medicine and Rehabilitation, Pediatrics, Geriatrics, Neurology, Hand Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Skilled Nursing Facility, Office, Home, and other settings where occupational therapy services are provided.