2025 CPT code 97167
Occupational therapy evaluation, high complexity for patients with comorbidities affecting occupational performance, requiring significant task modification or assistance.Typically, 60 minutes face-to-face with the patient and/or family.
Modifiers may be applicable to clarify specific aspects of the service provided. For example, modifier 59 may be used to indicate a distinct procedural service.
Medical necessity must be established by demonstrating that the patient's condition significantly impairs their occupational performance and requires skilled intervention from an occupational therapist.
Administered by a qualified occupational therapist, this evaluation requires advanced clinical reasoning to analyze a patient's condition and develop an appropriate treatment plan. It involves assessing physical, cognitive, and psychosocial aspects related to the patient's functional performance.
In simple words: An occupational therapist performs a thorough evaluation to assess how a patient's health issues affect their ability to perform daily activities. This involves a detailed review of their medical history, assessment of multiple areas impacting their performance, and creating a tailored treatment plan.This evaluation is for patients with complex health conditions and requires extra time and attention from the therapist.
Comprehensive occupational therapy evaluation of high complexity, encompassing: 1) Occupational profile and medical/therapy history, including extensive review of records and additional physical, cognitive, or psychosocial history related to current function. 2) Assessment of 5 or more performance deficits (physical, cognitive, or psychosocial) impacting activities and participation. 3) High-complexity clinical decision-making, involving analysis of patient profile, comprehensive assessment data, and consideration of multiple treatment options.
Example 1: A patient with multiple sclerosis experiences difficulties with fine motor skills, cognitive function, and psychosocial adaptation.The OT conducts a comprehensive evaluation to determine the extent of these deficits and formulate a treatment plan., A child with autism spectrum disorder has significant sensory processing challenges and difficulties with social interaction. The OT performs an in-depth evaluation to assess the impact of these challenges on the child's daily life and develop an intervention plan., An elderly patient post-stroke exhibits upper extremity weakness, balance problems, and cognitive decline.The OT conducts a comprehensive evaluation including physical, cognitive, and psychosocial assessments to develop a rehabilitation strategy.
Detailed documentation must include: 1) Occupational profile detailing the patient's history, current functional status, and goals. 2) Results of assessments for at least five performance deficits, specifying how they limit the patient's activities. 3) Clinical decision-making process explaining the chosen treatment options and their rationale. 4) Plan of care outlining treatment goals, frequency, duration, and anticipated outcomes.
- Revenue Code: M1A (OFFICE VISITS - NEW)
- Payment Status: Active
- Specialties:Occupational Therapy
- Place of Service:Office,Inpatient Hospital,Outpatient Hospital,Skilled Nursing Facility, Rehabilitation Facility, Home,Assisted Living Facility.