CPT code 97165
97165 CPT code in occupational therapy refers to an evaluation that an occupational therapist performs, which requires low-complexity clinical decision-making. This includes a brief analysis of the patient's history, specifically medical and therapy history, and an occupational profile, which includes information regarding an individual's daily habits, roles, activities, and routine.
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A low-complexity evaluation also includes assessments and observations that identify and target one to three performance deficit areas that impact a patient's ability to participate in daily activities. Evaluations can be finished without modification of tasks or assistance, such as verbal or physical activities, in about 30 minutes of face–to–face time with the patient and/or family.
In addition, the client presents with no comorbidities that affect occupational functioning.
Occupational therapists must understand the 97165 CPT code to utilize it for accurate documentation, reimbursement purposes, understanding levels of care, effective treatment planning, compliance with regulations, and delivering high-quality patient care.
Indications and conditions for using 97165 CPT code
The 97165 CPT code is commonly utilized for clients who require brief assessments and simple clinical decision-making. Some common indications or conditions for CPT code 97165 include Activities of Daily Living (ADL) training, adaptive equipment training, functional mobility training, and other conditions such as minor injuries or chronic conditions.
Activities of Daily Living
- Evaluations for individuals who require assistance with tasks such as bathing, dressing, and grooming
- May include minor postoperative conditions
- May include mild cognitive impairments
Adaptive Equipment Training
- Evaluations for individuals who need training on how to safely use adaptive equipment such as reachers, sock-aids and dressing hooks,
Functional Mobility Training
- Evaluations for individuals that require assistance for basic mobility tasks such as walking short distances, transferring, or navigating their environment safely.
- May include postoperative conditions
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Procedures and techniques covered under the 97165 CPT code
The 97165 CPT code encompasses procedures and techniques, including assessments, clinical observation, clinical decision-making, treatment planning and implementation, and documentation.
Assessment of functional abilities
- Therapists utilize standardized assessments to assess motor skills, including fine and gross motor skills, social skills, cognitive functioning, and processing skills
- Identifying critical performance and functional deficits
Development of intervention plans
- Establishing a baseline and SMART goals based on assessment results.
Implementation of therapeutic activities
- Therapeutic interventions based on assessment findings
- Patient and caregiver education of assessment findings, deficit areas, and treatment plan
Documentation requirements
- Accurate and detailed documentation of evaluation findings, identified areas of deficits, intervention plan, and treatment plan
- Ensure that documentation meets payer guidelines for low-complexity evaluations
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Documentation guidelines for 97165 CPT code
Accurate documentation for the 97165 CPT code is essential for proper billing and reimbursement. Requirements include patient information such as medical and therapy history, assessment findings, clinical decision-making, and a well-established treatment plan. Some common pitfalls to avoid include errors in coding, missing documentation, and double billing.
Examples of required documentation
- Patient information and brief medical history
- Patient A (DOB: 12/31/1972), evaluated on 7/18/2024, has arthritis in the hands, predominantly impacting the right dominant hand. Patient A fractured her wrist four months ago and has been treated. Patient A is a teacher and enjoys writing and fashion.
- Assessment and findings
- Fine Motor Skills: Difficulty with writing and buttoning tops
- Gross Motor Skills: Intact, no issues observed
- Cognitive and processing: Mild difficulty with executive functioning tasks, including attention to task
- Social skills: Intact, no issues observed
- Treatment plan/clinical decision-making
- Goals: May include improving fine motor skills such as writing and buttoning tops and increasing attention to the task
- Recommendations: Frequency, duration, and time
- Patient education
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Reimbursement and billing tips for the 97165 CPT code
- Medicare will cover low-complexity evaluations and occupational therapy services when deemed medically necessary. Accurate and detailed documentation is necessary to ensure coverage for Medicare and insurance.
- Private insurance varies between different plans and policies, and it is best to check with the insurance provider to determine if pre-authorization or other documentation is required.
- Medicare reimbursement rates are standardized for CPT codes but can vary by geographic location.
- It is also important to understand that insurance plans and Medicare have annual therapy caps or limitations on the number of therapy services a patient can receive or set specific session limits.
- It is essential to provide medical necessity to justify therapeutic services.
Compliance and regulatory considerations for the 97165 CPT code
Adhering to CPT guidelines and healthcare regulations is essential for properly using the 97165 CPT code. 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 example
CPT codes, like the 97165 CPT code, can be utilized in various settings. One such example would be a person who experienced a work-related injury that required minor surgery and was then referred to an occupational therapist.
The occupational therapist would begin the evaluation process with a brief medical history and an occupational profile focusing on her roles, habits, and routines. Then, she would identify performance deficits and perform a standardized assessment.
Assessment measurements would include:
- Pain levels
- Range of motion
- Strength
- Functional abilities related to their job tasks of being a teacher
The treatment plan could include six weeks of one 45-minute occupational therapy session a week focusing on fine motor skills and pain management to facilitate the employee's return to work. This may include adjustments to their work environment, therapeutic interventions to improve their condition, or adaptive equipment.
The patient's outcome is improved fine motor coordination, strength, control, and the ability to resume her role as an educator.
97165 CPT code is used for low-complexity occupational therapy evaluations that incorporate a brief medical and therapeutic history, occupational profile, one to three performance deficit areas, and standardized assessment tools to assess the current level of function.
Accurate and detailed documentation is pertinent and includes the assessment findings, clinical decision-making, and treatment plan. Proper utilization and adherence to regulations and guidelines are essential to ensure effective treatment planning, reimbursement rates, and high-quality client-centered care.
How EHR and practice management software can save occupational therapists time
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 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
CPT code 97165 Low Complexity Initial Evaluation. Therapy Playground. https://therapyplayground.com/cpt-code-97165-low-complexity-initial-evaluation/
CPT® Assistant February 2017 / Volume 27 Issue 2. (n.d.). New Occupational Therapy Evaluation Codes. Aota.org.
CPT® code 97165 - Occupational Therapy Evaluations - Codify by AAPC. CPT® Code 97165 - Occupational Therapy Evaluations - Codify by AAPC. https://www.aapc.com/codes/cpt-codes/97165
