97167 CPT code
97167 CPT code in occupational therapy refers to a high-complexity evaluation utilized for patients with high-complexity needs. It requires extensive or high-complexity clinical decision-making by the occupational therapist.
A high-complexity evaluation encompasses an extensive occupational profile, medical and therapy history, and an additional review of the client's physical, cognitive, and psychosocial history related to functional performance.
It also includes an assessment(s) that identifies five or more performance deficits that limit or restrict activities.
Clients may have multiple comorbidities and require significantly modifying tasks or assistance. For a high-complexity evaluation, the typical face-to-face time is 60 minutes. In addition, occupational therapists consider several treatment options.
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What is the billing code 97167?
Therapists utilize the 97167 CPT code for clients who require high analytic and complex clinical decision-making by an occupational therapist to analyze assessments and develop a treatment plan.
Some common indications for the 97167 CPT code include activities of daily living, adaptive equipment training, and functional mobility training.
- Activities of Daily Living: Evaluations for individuals who require assistance with tasks such as bathing, dressing, eating, and grooming
- Adaptive Equipment Training: Evaluations for individuals who need in-depth training on how to safely use adaptive equipment such as wheelchairs, walkers, and adaptive kitchen and feeding utensils
- Functional Mobility Training: Evaluations for individuals that require assistance for transfers, walking, balance, navigating uneven surfaces, and stair negotiations
Some common conditions include neurological, orthopedic, and developmental conditions, which may include Multiple Sclerosis, Muscular Dystrophy, Parkinson's Disease, Spinal Cord Injuries (SCIs), strokes, severe arthritis, amputations, fractures, or developmental conditions.
Procedures and techniques covered under 97167 CPT code
The 97167 CPT code encompasses procedures and techniques that include a comprehensive medical and therapeutic history, assessment of functional abilities, clinical observation, a high level of analytical, clinical decision-making, treatment planning, implementation of therapeutic activities, and in-depth documentation.
Assessment of functional abilities
- Therapists utilize standardized assessments to assess motor skills, cognitive, and psychosocial levels.
- Identify five critical performance and functional deficits such as physical, cognitive, and psychosocial.
Implementation of therapeutic activities
- Therapeutic interventions based on assessment findings
- Patient and caregiver education of assessment findings, deficit areas, and treatment plan
- Activities are focused on ADL training, adaptive equipment training, and 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 evaluation findings, five identified areas of deficits, intervention plan, and treatment plan
- Ensure that documentation meets payer guidelines for high-complexity evaluations utilizing 97167 CPT code
- Keep track of regular sessions, progress notes, and re-evaluation reports
Documentation guidelines for 97167 CPT Code
Accurate documentation for the 97167 CPT code is essential for proper billing and reimbursement. Requirements include patient information, including a very comprehensive medical and therapeutic history, assessment findings, analytic clinical decision-making, and a well-established treatment plan.
Some common insurance billing pitfalls to avoid include general clerical coding errors, double billing, and missing documentation.
Examples of required documentation
- Patient information and thorough medical history
- Patient A is a 65-year-old female (DOB: 12/31/1958) evaluated on 8/2/2024 presenting with comorbidities of diabetes and rheumatoid arthritis and had a stroke five months ago impacting her left dominant hand and has been treated. She presents with difficulty with balance, weakness in her left upper extremity, and performing ADL tasks such as dressing and bathing.
- Assessment and findings
- Assessment results indicate significant difficulty with self-care, mobility, and cognition
- Treatment plan/clinical decision making
- Goals: To improve strength in the left upper extremity, ADL retraining, specifically dressing, adaptive equipment training, visual-perceptual, balance exercises, and increasing memory and attention to task
- Recommendations: Frequency, duration, and time
- Patient Education
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Reimbursement and billing tips for 97167 CPT code
Medicare will cover high-complexity evaluations and occupational therapy services when deemed medically necessary. It is necessary to include accurate and detailed documentation to cover 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 essential to understand that insurance plans and Medicare have annual therapy caps or limitations on the number of therapy services a patient can have or set specific session limits. It is important to provide medical necessity to justify therapeutic services.
Compliance and regulatory considerations for 97167 CPT code
Adhering to CPT guidelines and healthcare regulations is essential for properly using the 97167 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.
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The 97167 CPT code is designated for high-complexity occupational therapy evaluations that involve a comprehensive review of significant medical and therapeutic history, occupational profile, and standardized assessment tools to assess the current function level and identify at least five performance deficit areas.
Accurate and detailed documentation is critical 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, appropriate reimbursement rates, and high-quality, client-centered care.
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How EHR and practice management software can save occupational therapists time on 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
- 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
- CPT 97167 for OT Evaluation High Complexity. Therapy Playground. https://therapyplayground.com/cpt-97167-for-ot-evaluation-high-complexity
- CPT® Assistant February 2017 / Volume 27 Issue 2. New Occupational Therapy Evaluation Codes. Aota.org.
