97168 CPT code

97168 CPT code in occupational therapy refers to re-evaluating an established care plan.

According to AOTA, CPT code 97168 "is performed when a documented change in functional status or a significant change to the care plan is required. Typically, 30 minutes are spent face-to-face with the patient and family."

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It is most commonly utilized when an occupational therapist revisits the patient's treatment plan established during the initial evaluation to assess their progress and make necessary changes to therapy, such as treatment goals based on the patient's current level of function and response to therapy. It allows therapists to assess the effectiveness of the treatment plan, modify the treatment plan based on the patient's change in status, and provide updated documentation necessary for continued therapy and ongoing services.

Eligibility criteria and critical components of 97168 CPT code

• Must have a prior evaluation and established plan of care

• Medical necessity for re-evaluation, such as a change in status, not meeting goals, necessary adjustments to the treatment plan are required, or the patient is in a different phase of therapy

• Occupational therapist utilizes their clinical and professional judgment and skills to determine if re-evaluation is necessary

• Occupational profile-review of the patient's history and condition since the evaluation

• Assessment of current functional status

• Revised plan of care: Revision of therapy goals and treatment plan if necessary

• Documentation of results and updated treatment plan

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What is procedure code 97168?

Therapists use the 97168 CPT code for clients who require a re-evaluation by the occupational therapist due to a change in status. Indications for the 97168 CPT code include activities of daily living, adaptive equipment training, and functional mobility training. Some common conditions include but are not limited to progressive neurological conditions such as Multiple Sclerosis (MS), Parkinson's Disease, cognitive challenges and changes, changes in an individual's mental health, and pain management.

Activities of Daily Living

• Change in Functional Status: Either lack of progress, improvement, or deterioration of the ability to perform ADL activities assessed during the initial evaluation, such as bathing, dressing, grooming, hygiene.

• Environmental Changes: A re-evaluation may be warranted if the patient is experiencing environmental changes such as re-location to an assisted living facility.

Adaptive Equipment Training

• A re-evaluation may be warranted if physical abilities have declined, improved, or not changed.

• Introduction to alternative methods, different adaptive equipment or technology, or modifications may be necessary.

Functional Mobility Training

• Re-evaluation may be warranted if the patient's ability to ambulate and be mobile safely has changed.

• If there are updates on injury status or surgery.

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Procedures and techniques covered under 97168 CPT code

Re-assessment of functional abilities

Occupational therapists will reassess the patient's physical abilities and functions, such as strength, range of motion, and coordination. This also includes ADL skills, IADL skills, cognitive function, perceptual abilities, and mobility.

Development of intervention plans

• Revision of current occupational therapy goals and adjust them based on whether clients have achieved the goals or whether those goals still need to be met, are in progress, or new condition

• Set new goals as necessary with the patient's current level of function

• Update treatment plan to reflect changes and modifications of treatment strategies and intervention methods

Implementation of therapeutic activities

• Apply therapeutic interventions based on updated findings

• Patient and caregiver education on updated assessment findings, deficit areas, and treatment plan

• Activities are focused on ADL training, adaptive equipment training, functional mobility training and can also include home modifications, community resources, hand therapy, sensory integration therapy, manual therapy, and cognitive rehabilitation

Documentation Requirements

• Accurate and detailed documentation of updated evaluation findings, identified areas of deficits, intervention plan, and treatment plan

• Ensure that documentation meets payer guidelines for high-complexity evaluations utilizing code 97168

• Keep track of regular sessions, progress notes, and re-evaluation reports

Documentation guidelines for 97168 CPT Code

Ensuring accurate documentation for the 97168 CPT code is essential for proper billing and reimbursement. Requirements include medical necessity and change in patient status. It is important to include patient information, including a comprehensive medical and therapeutic history, re-evaluation findings, clinical decision-making, and a well-established treatment plan.

Some general pitfalls to avoid during documentation include:

• Not having enough documentation information

• Having clerical errors such as typos

• Utilizing incorrect codes

• Incorrect billing information

Example of required documentation

• Patient A reports increased pain in the left shoulder and difficulty putting on tops. Upon re-evaluation, the patient has demonstrated a decreased range of motion and increased pain levels. ADL goals are updated to include adaptive strategies to assist with dressing.

• Assessment and findings
  • Assessment results indicate significant difficulty with self-care

• Treatment plan/clinical decision making
  • Goals: To improve strength in the left upper extremity, ADL retraining, specifically dressing and adaptive equipment training
    
  • Recommendations: Frequency, duration, and time
    
  • Patient education

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Reimbursement and billing considerations

When a professional assessment by a clinician indicates marked improvement or decline or an unexpected change in the client's condition or functional status that was not in the plan of care, a re-evaluation is separately payable.

It is imperative to provide medical necessity for a re-evaluation. It is important to note that progress reports are a routine aspect of therapeutic services.

According to CMS, "a routine continuous assessment of the patient's expected progress in accordance with the plan of care is not considered to be a medically necessary service and is not separately reimbursable as a re-evaluation."

Compliance and regulatory considerations

Adhering to CPT guidelines and healthcare regulations is essential for properly using CPT code 97168. Ensuring compliance through accurate coding guidelines and detailed documentation supports high-quality patient care and helps prevent penalties, legal issues, and operational disruptions.

Case studies and 97168 CPT Code examples

An example of when to use the 97168 CPT Code is if a patient receiving therapeutic services develops a new condition or diagnosis. For instance, an occupational therapist may treat a patient for a left hip replacement when the patient begins to experience new wrist pain.

The clinician determines that the wrist pain is related to using adaptive equipment. The treatment plan is then updated to include 6–12 weeks of occupational therapy, 1–2 times per week for 60 minutes, focusing on pain management, ADL training, and adaptive equipment training.

This approach aims to improve the patient's strength, endurance, and overall independence while reducing pain. As a result, the patient achieves enhanced functionality and greater autonomy.

97168 CPT code is designated for patients undergoing therapy who experience a significant and unanticipated change in their condition, such as an improvement, decline or shift in functional status, necessitating a re-evaluation to optimize rehabilitation outcomes.

Accurate and comprehensive documentation is crucial, encompassing assessment findings, clinical decision-making, and updates to the treatment plan. Proper use of this code, in line with regulations and guidelines, ensures effective treatment planning, appropriate reimbursement, and the delivery of high-quality, patient-centered care.

How EHR and practice management software can save occupational therapists time with insurance billing

EHRs with integrated billing software and clearing houses, such as TheraPlatform, offer occupational therapists significant advantages in creating an efficient insurance billing process. The key is minimizing the amount of time dedicated to developing, sending, and tracking medical claims through features such as automation and batching.

What are automation and batching?

• Automation refers to setting up software to perform tasks with limited human interaction.

• Batching or performing administrative tasks in blocks of time at once allows you to perform a task from a single entry point with less clicking.

Which billing and medical claim tasks can be automated and batched through billing software?

• Invoices: Create multiple invoices for multiple clients with a click or two of a button or set up auto-invoice creation, and the software will automatically create invoices for you at the preferred time. You can even have the system automatically send invoices to your clients.

• Credit card processing: Charge multiple clients with a click of a button or set up auto credit card billing, and the billing software will automatically charge the card (easier than swiping!)

• Email payment reminders: Never manually send another reminder email for payment again, or skip this altogether by enabling auto credit card charges.

• Automated claim creation and submission: Batch multiple claims with one button click or turn auto claim creation and submission on.

• Live claim validation: The system reviews each claim to catch human errors before submission, saving you time and reducing rejected claims.

• Automated payment posting: Streamline posting procedures for paid medical claims with ERA. When insurance offers ERA, all their payments will post automatically on TheraPlatform's EHR.

• Tracking: Track payment and profits, including aging invoices, overdue invoices, transactions, billed services, service providers.

Utilizing billing software integrated with an EHR and practice management software can make storing and sharing billing and insurance easy and save OTs time regarding insurance billing for therapists.

Resources

TheraPlatform is an all-in-one EHR, practice management, and teletherapy software built for therapists to help them save time on admin tasks. It offers a 30-day risk-free trial with no credit card required and supports different industries and sizes of practices, including occupational therapists in group and solo practices.

More resources

• Therapy resources and worksheets
• Therapy private practice courses
• Ultimate teletherapy ebook
• The Ultimate Insurance Billing Guide for Therapists
• The Ultimate Guide to Starting a Private Therapy Practice
• Insurance billing 101
• Practice management tools

Free video classes

• Free on-demand insurance billing for therapist course
• Free mini video lessons to enhance your private practice
• 9 Admin tasks to automate in your private practice

References

1. Billing and Coding: Therapy evaluation, Re-Evaluation and Formal Testing. http://CMS.gov Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=53309
2. CPT® Assistant February 2017 / Volume 27 Issue 2. New Occupational Therapy Evaluation Codes. Aota.org
3. Re-Evaluations 97164 and 97168 - tip of the month. https://www.centuryrehab.com/wp-content/uploads/2019/08/TOTM-Re-evaluation.pdf