AOTA Continuing Education Article: New Occupational Therapy Evaluation CPT® Codes (PDF)

Earn.1 AOTA CEU (one contact hour and...

Earn.1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. New Occupational Therapy Evaluation CPT® Codes: Coding Overview and Guidelines on Code Selection Catherine Brennan, MA, OTR/L, FAOTA 5. Utilize concepts from the Occupational Therapy Practice Consultant and Peer Review Coordinator Framework: Domain and Process, 3rd Edition (American Occu- Minnesota Occupational Therapy Association pational Therapy Association, 2014) to enhance the occupa- St. Paul, Minnesota tional therapy evaluation process Mary Jo McGuire MS, OTR/L, OTPP, FAOTA INTRODUCTION Clinical Assistant Professor On January 1, 2017, new CPT codes will go into effect for School of Behavioral and Health Sciences occupational therapy evaluations. The American Medical Asso- Walsh University ciation’s (AMA’s) Common Procedural Terminology (CPT®) 2017 North Canton, Ohio book will list three levels of occupational therapy evaluation and one level of re-evaluation under the Physical Medicine Christina Metzler and Rehabilitation section of the CPT code set. The previous Chief Public Affairs Officer codes have been deleted and replaced with new codes, with The American Occupational Therapy Association new code numbers and new requirements for use (see Table 1 Bethesda, MD on p. CE-5). To use the correct code in the new system, occupational ther- This CE Article was developed in collaboration with AOTA’s apists will have to attend to new criteria that distinguish three Administration & Management Special Interest Section. different levels of initial evaluation. This article is intended to provide an overview of the codes to assist occupational thera- ABSTRACT pists with making correct coding choices that reflect modern On January 1, 2017, four new codes will go into effect for occupational therapy practice. Three new CPT codes replace occupational therapy evaluations. The American Medical code 97003 and describe differences in complexity of evalua- Association’s 2017 Common Procedural Terminology (CPT®) tions, ranging from low (i.e., straightforward), designated by Manual will list three levels of occupational therapy evalu- code 97165; to moderate (i.e., involved), designated by code ation to replace CPT® code 97003 and one level of re-eval- 97166; to high (i.e., very complex), represented by code 97167. uation to replace CPT® code 97004 under the Physical Previously, when an occupational therapist performed an evalu- Medicine and Rehabilitation section of the codebook. To use ation of a client, only one code (97003) was available to reflect the correct codes in the new system, occupational therapists the clinical work accomplished during that evaluation session. will have to attend to new criteria that distinguish differing There is one re-evaluation code: code 97168. levels of evaluation. This article provides an overview of the The code descriptors and introductory guidelines for their new evaluation codes to assist occupational therapists with use are published in the CPT code book and are available on making correct coding choices that reflect modern occupa- AOTA’s website, at www.aota.org. New CPT code books are tional therapy practice. available in print and online from the AMA. The AMA also plans in early 2017 to publish an article explaining the codes in LEARNING OBJECTIVES the CPT Assistant Newsletter, which is available by subscription After reading this article, you should be able to: (https://commerce.ama-assn.org/store). 1. Discuss how CPT describes the occupational therapy evalua- The new codes were developed through a process involving tion and reevaluation codes the AMA (which develops, publishes, and owns the CPT sys- 2. Identify each component of the new occupational therapy tem), the American Occupational Therapy Association (AOTA), evaluation codes and other professional societies. Payers, including Medicare, 3. Describe the differences between low-, moderate-, and Medicaid, and insurance providers, use these codes to identify high-complexity occupational therapy evaluation codes services for payment. 4. Select an appropriate initial evaluation code that reflects the Medicare will begin using these codes on January 1, 2017, level of complexity of the evaluation performed and most other third-party payers (e.g., Medicaid, insurers) will DECEMBER 2016 l OT PRACTICE, 21(22) ARTICLE CODE CEA1216 CE-1  Continuing Education Article CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682). follow this procedure by developing individual payer policies on to each of the CPT factors in the context of the whole evaluation the use of and payment for codes. to meet the client’s needs. To understand how CPT described the occupational therapy The three components are what must be validated in evaluation and reevaluation codes, it is important to review and choosing a level, but a sufficient evaluation must be provided as understand the precise language in the 2017 AMA CPT manual. appropriate to occupational therapy practice. Why a particular It provides the following introduction to the codes for Occupa- level was chosen should be supported in the documentation of tional Therapy Evaluation: the evaluation. To assist in selecting an evaluation code level, the codes Occupational therapy evaluations include an occupational direct that each of the three previously noted components must profile, medical and therapy history, relevant assessments, be given a complexity level: low, moderate, or high. and development of a plan of care, which reflects the ther- apist’s clinical reasoning and interpretation of the data. CHOOSE AN APPROPRIATE LEVEL Coordination, consideration, and collaboration of care Levels must be determined specifically for each of the three with physicians, other qualified health care professionals, components in order to choose the correct code. For a higher or agencies is provided consistent with the nature of the level of evaluation, all three components must be of the higher problem(s) and the needs of the patient, family, and/or level. For example, if the profile and history are moderate and other caregivers. (AMA, 2016, p. 664) the assessment of occupational performance and identification The definition follows the approach to evaluation in the of deficits is moderate, but the clinical decision making compo- Occupational Therapy Practice Framework: Domain and Pro- nent is high, the evaluation must still be coded moderate. Ther- cess, 3rd Edition (Framework; AOTA, 2014). The Framework apists must remember that they are ethically, and in some cases will be referenced throughout this article, as it provides legally, required to choose and report the correct code. The code important direction for conducting appropriate, best-practice design considers the presenting client condition, the analytical evaluations. work of the therapist, and the assessment and identification of The new evaluation code descriptions in the CPT code set the scope and nature of the client’s performance concerns and promote optimal occupational therapy practice. By conducting goals. A proper evaluation involves a broader view and other an occupational profile, completing assessments, and presenting components. But choosing a level is necessary to report the the breadth of client functional concerns, occupational ther- correct code. apists capture and express the distinct value of occupational The following describes how each of the three components therapy evaluation services. The occupational therapy evalua- affects the code level based on the language of the actual code tion process communicates to others the full scope of occupa- descriptors in the manual. tional therapy practice. In this sense, the codes can be a tool to promote the distinct value of occupational therapy. Level of Profile and History The occupational therapy process as described in the Framework DETERMINING THE CORRECT LEVEL OF EVALUATION is reflected in the code language, especially in its requirement of The new CPT evaluation code descriptors and guideline lan- completing an occupational profile and a medical and therapy guage define the exact elements of an evaluation: history. The key terms in CPT to consider when differentiating l Occupational profile and client history (medical and and choosing a level for this component, in addition to the types therapy) and extent of history and records, are Brief (Low), Expanded l Assessments of occupational performance (Moderate), and Extensive (High), which are related to cate- l Clinical decision making gorizing the elements of occupational profile and history to l Development of plan of care determine the level. Identifying and reporting the complexity level of an eval- uation focuses on the first three of these factors—profile and Occupational Profile history, assessment and determination of deficits, and clinical The occupational profile provides an understanding of the decision making. These three factors must be “scored” and client’s occupational history and experiences, patterns of daily defensible documentation written as part of the medical record living, interests, values, and needs. The client’s problems and to support the choice of a code level. concerns about performing occupations and daily life activities The three components—occupational profile and history, are identified as part of the profile. The client’s priorities for assessment, and clinical decision making—are the factors outcomes are also determined. that payers and others will review to ensure that the therapist To decide on the level of occupational profile that must be has chosen the right code level. The documented plan of care completed, the therapist must consider the presenting prob- reflects the process and outcomes and the therapist’s attention lem(s), the reason(s) for referral, and the client’s goals. CE-2 ARTICLE CODE CEA1216 DECEMBER 2016 l OT PRACTICE, 21(22) Earn.1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. Client Medical and Therapy History How Does CPT Describe Levels of Assessment? The client’s medical and therapy history is reviewed and consid- In addition to performance deficits, an element of determin- ered in order to identify issues that may affect the current prob- ing the code level is the complexity of the assessment pro- lem. How much of the history is necessary depends on why the cess itself. The CPT code set definition for clinical decision client is seeking services and what the occupational therapist making, discussed later in this article, includes language that needs to know to continue with assessing and developing the can be applied to thinking about how targeted or extensive plan of care. The referral for therapy may also provide additional assessments are. This language emphasizes the importance information. It can also come from medical records of past and of both the collection of data and its analysis. The key words current care. to consider from CPT in differentiating levels of assessment in an occupational profile are problem focused, detailed, and Physical, Cognitive, or Psychosocial History comprehensive. To achieve expanded (moderate) or extensive (high) levels of profile and history, the therapist must also review with the What Are Performance Deficits? client their physical, cognitive, or psychosocial history related to The introduction to the new CPT evaluation codes identifies current functional performance. and defines areas of performance deficits that are very similar to descriptions in the Framework and encompass the full range Level of Assessment of Occupational Performance of occupational therapy’s scope of practice. As previously noted, The second component in determining the level of the CPT the CPT states that lack of skills or limitations in physical, cog- evaluation service considers factors related to both the assess- nitive, or psychosocial areas must be linked to the performance ment process and the identification of performance deficits deficits that result in activity limitations and/or participation resulting in activity limitations and/or participation restrictions. restrictions. Performance deficits that do not result in activity limitations Occupational therapists may also address other issues, such and/or participation restrictions that are meaningful to the as context and environment. client do not count. The International Classification of Functioning, Disability and Health (World Health Organization [WHO], 2001) is also a Assessment Process useful tool in understanding performance deficits that result in The therapist should consider all the information gathered activity limitations or participation restrictions: “Activity limita- in the history and occupational profile, and the data from tions are difficulties an individual may have in executing activ- the assessment process, to determine (with the client) ities” and “participation restrictions are problems an individual the priority of occupational performance deficits to be may experience in involvement in life situations” (p. 123). addressed. The Framework does not define or use the term performance Ideally, the therapist will use standardized assessments deficits; the Framework and occupational therapy practice focus to identify a performance deficit and decide with the client on the capacities of clients and their skills or potential skills. whether that deficit should be addressed. The physical, cogni- However, the CPT definitions provide ample areas in which to tive, and psychosocial skills areas identified by CPT encompass identify client needs and goals. Defining deficits is viewed in the broad areas of skills, but these may be broken into component CPT context as the process of identifying what areas or goals the skills for assessment and possibly for intervention. Components occupational therapy plan will address. The CPT definitions can of skills, such as range of motion or ability to sequence, should be understood in relation to the Framework’s Table 1: Occupa- also be assessed, including in physical, cognitive, and psychoso- tions as well as the concepts in Table 2: Client Factors and Table cial areas. 3: Performance Skills. Lack of skills that affect activity and participation Performance deficits are really the “why” of an intervention may also be identified by non-standardized assessment, plan. Documentation is where the clinician must explain perfor- although many payers are beginning to require standard- mance deficits’ impact on functional performance, and goals in ized approaches. All assessment tools and approaches used the plan of care should reflect the outcome performance to be should be explicitly documented in the medical record, and achieved. the rationale supporting the use of non-standardized tools It is important to note that the count of client-relevant is highly recommended. The CPT does not fully encompass performance deficits is only one factor in assigning the level all that occupational therapy may or should address in the of the code. The complexity of the occupational profile and assessment. The Framework and best practice provide an medical history, and the complexity of the clinical reasoning, expansive view of what the occupational therapist must which result in the development of the plan of care, must also assess to identify strengths, areas that may be able to be be considered. improved, and areas where compensations or alternative Because the number of deficits will be subject to review as strategies for performance are designed. the new codes are implemented, documentation of these is DECEMBER 2016 l OT PRACTICE, 21(22) ARTICLE CODE CEA1216 CE-3  Continuing Education Article CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682). very important. The therapist’s clinical judgment and reasoning tasks in assessment or assistance are no modification or assis- about the overall needs of the client, the client’s expectations for tance (low), minimal to moderate (moderate), and significant this episode of care, and the overall complexity of the presenting (high). client situation will dictate the number of deficits identified. Selection of Interventions. Level of Clinical Decision Making Selecting may be simple or complex. This affects the level of The new CPT codes for occupational therapy evaluation identify clinical decision making. For instance, treatment of hemipare- a component of clinical decision making that affects the code sis may involve choosing among several options for treatment, level selected. Best practice in occupational therapy requires adaptation, or compensatory activities. But treatment of an clinical reasoning to occur throughout the evaluation process: acute shoulder hemi-arthroplasty may be driven by a limited in decisions about the questions to ask in the occupational number of treatment options. The key words in the selection of profile and history, in the choice of assessments and tests used interventions are limited number (low), several (moderate), and to measure performance, and in the identification and prior- multiple (high). itization of goals and outcomes. Although clinical decision The therapist considers all these factors to determine making is pervasive, the CPT guidelines for code selection allow what level the component of clinical decision making should for consideration of certain variables in determining a level be. Note that each factor in clinical decision making can be of clinical decision making. Identifying and documenting the individually determined. The factors are considered by the complexity of clinical reasoning used at each step of the process therapist individually and documented individually, but it is will validate the chosen level of evaluation code. the therapist’s view of how complex the overall process was that affects the level. Specified Criteria for Clinical Decision Making Level The CPT definitions and code selection guidelines provide clear CLINICAL VIGNETTES: IDENTIFYING THE CORRECT EVALUATION delineation of factors that can be related to not only determin- LEVEL ing the level of clinical decision making component, but also Low-Complexity Occupational Therapy Evaluation (97165) factors that affect other components. The CPT code language The client was a 69-year-old retired female who fell at home, speaks to interrelated factors and thus an interrelated process sustaining a closed distal radius fracture to the right dominant that must be considered in determining the level of clinical wrist. On her return visit to the physician, she had limited range decision making. of motion (ROM) and was referred to occupational therapy for Assessment Process. As noted and defined in the previous ROM hand strengthening. section on assessment and performance deficit identification, The occupational therapist reviewed the occupational the clinical decision making section in the CPT describes levels profile and the medical and therapy history and observed the of analysis and assessment that are related to determining client performing activities. The therapist assessed sensation, the level of both the assessment and clinical decision-making strength, ROM, and edema. Sensation was normal and there component. The key words are Problem-focused (Low), Detailed were no vascular issues. Mild edema was observed to be pres- (Moderate), and Comprehensive (High). ent in the client’s wrist and digits. The therapist evaluated her Impact of Comorbidities. The type, number, and complexity of ROM and found it was within normal limits at the shoulder, comorbidities affecting occupational performance or that result normal for elbow extension and flexion, and moderately in participation restrictions are identified as affecting the eval- limited in the wrist and forearm. Grip and pinch strength were uation code level, in relation to clinical decision making. Only decreased compared with the non-dominant hand, making it those that impact performance should be considered. difficult for her to perform dressing and home management For example, a secondary diagnosis of chronic obstructive activities, such as cleaning. The occupational therapist had pulmonary disease may influence the client’s breathing and the client complete the Disabilities of the Arm, Shoulder and fatigue level, affecting completion of desired activities of daily Hand Assessment (Kennedy, Beaton, Solway, McConnell, & living (ADLs). Bombadier, 2011). Assessment Modification and Need for Assistance. The Based on the client’s occupational profile, history, and CPT language describes the levels of assistance or modifica- assessment results, the occupational therapist developed a plan tion that may be needed to enable completion of assessments of care addressing performance deficits in ADLs and instru- that contribute to the level of clinical decision making. The mental ADLs (IADLs) due to decreased active range of motion, language also gives examples that assistance may be physical, decreased strength, limits in gripping, and increased edema. verbal, or some other form. Any modifications or adjust- The therapist chose the low-complexity evaluation code for ments in assessing performance deficits and activity limita- the following reasons: tions should be documented to show the relationship to the l Medical history was brief; the presenting problem was the level of evaluation code chosen. The key words for modifying primary focus of the evaluation. CE-4 ARTICLE CODE CEA1216 DECEMBER 2016 l OT PRACTICE, 21(22) Earn.1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. l Three performance deficits were to be addressed in the plan l Clinical decision making was of low complexity, as data from the of care due to wrist fracture: client’s history, profile, and assessments were problem focused Dressing (inability to fasten clothing due to active ROM and required a review of a limited number of treatment options. [AROM], grip and strength deficits) No comorbidities affected the current problem, and no modifi- Home management (difficulty pushing vacuum cleaner cations were required to complete the assessment. due to wrist and forearm AROM limitations) M eal preparation (difficulty grasping utensils and Moderate-Complexity Occupational Therapy Evaluation (97166) lifting pans due to edema, AROM, and strength The 68-year-old male presented with a previous amputation problems) below his left knee as well as a recent hospitalization for a Table 1. Descriptors of New CPT Occupational Therapy Evaluation Codes New CPT® Code CPT® Descriptors for OT Evaluation Codes Occupational therapy evaluation, low complexity, requiring the following components: An occupational profile and medical and therapy history, which includes a brief history, including review of medical and/ or therapy records relating to the presenting problem An assessment(s) that identifies one to three performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions 97165 Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. The client presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the client and/or family. Occupational therapy evaluation, moderate complexity, requiring the following components: 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 An assessment(s) that identifies three to five performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions 97166 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. The client may present with comor- bidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable the client to complete the evaluation component. Typically, 45 minutes are spent face-to-face with the client and/or family. Occupational therapy evaluation, high complexity, requiring the following components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance An assessment(s) identifying five or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions 97167 The clinical decision making is of high analytic complexity, which includes an analysis of the client profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. The client presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable the client to complete evaluation component. Typically, 60 minutes are spent face-to-face with the client and/or family. Reevaluation of occupational therapy established plan of care, requiring the following components: An assessment of changes in client functional or medical status with revised plan of care An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions 97168 and/or goals A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the client and/or family. DECEMBER 2016 l OT PRACTICE, 21(22) ARTICLE CODE CEA1216 CE-5  Continuing Education Article CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682). wound on his right knee and generalized weakness. His past High-Complexity Occupational Therapy Evaluation (97167) medical history included degenerative joint disease affecting The client was a 29-year-old male who had sustained a head his shoulder, diabetes mellitus, neuropathy, and retinopathy. He injury with a loss of consciousness while snowboarding 12 lived alone in his own one-level home, which had no structural weeks earlier. Medical evaluation showed a traumatic brain home modifications, and he received some help from a nearby injury due to a right-sided subdural hematoma. The client daughter. He ambulated with a walker and did not use a low- underwent a right frontal and temporal craniotomy and other er-extremity prosthesis. procedures. His medical history included multiple previous The occupational therapist reviewed the occupational profile concussions during high school, but no prior cognitive problems and the medical and therapy history and observed the client were noted. performing desired occupations and activities. The therapist The client was a computer technician, active in many sports, assessed upper extremity (UE) strength, functional mobility, and living independently in an apartment prior to the accident. vision, depression, and ADLs. The results showed weakness in He indicated some loss of memory, and his accompanying shoulder and elbow muscle strength, minimal assistance needed caregiver reported that he was isolating himself from family and with ADLs and bed-to-chair transfers, and moderate assistance friends. needed to come to standing from the toilet. The client’s vision was The occupational therapist reviewed the client’s occu- impaired, resulting in safety issues in ADL and IADL tasks in his pational profile and the medical and therapy history and home and community. The client experienced significant diffi- observed him performing desired occupations and activities. culty in daily activities, including mobility inside the house and in The therapist performed multiple assessments, including his garden. He also noted that he was having difficulty monitoring those for ADLs, muscle tone, gross and fine motor coordi- and maintaining his glucose levels because of changes in his activ- nation, sensory discrimination, and executive function. An ity level without modifying his food intake. His low vision also interview with the client about his feelings about friends affected his ability to administer insulin appropriately. and family revealed significant skill limitations related to Based on the client’s occupational profile, history, and assess- active and supportive social relationships. The therapist ment results, the occupational therapist developed a plan of care identified performance problems in ADLs related to left- addressing performance deficits in dressing, mobility, and toilet sided neglect, left UE weakness, decreased touch pressure transfers, with potential need for adaptive equipment, visual sensation in his left hand/forearm, and pain. Short-term aids, and home modifications. memory loss, impulsivity, and decreased mental flexibility The occupational therapist chose the moderate-complexity also were observed. These observations were supported by evaluation code for the following reasons: results of the Executive Function Performance Test (Baum et l An expanded review of the medical history and profile was al., 2008), which also showed multiple deficits in sequenc- required, which included an additional review of physical ing, initiation of tasks, and safety/judgment, which affected history given the number of other identified conditions that the client’s ADLs. affected current functional performance. Based on the client’s occupational profile, history, and assess- l Four performance deficits were to be addressed in the plan ment results, the occupational therapist developed a plan of of care due to the left below knee amputation and the recent treatment that included addressing performance and safety defi- infection in the client’s right knee. cits in ADLs; increasing left side body awareness; pain reduction Dressing (limitations due to weakness in shoulder and strategies; and compensatory strategies to improve memory, elbow) organizational skills, and daily routines, including improving Functional mobility (fall risk; difficulty transferring insid pursuit of social activity. The therapist discussed safety issues and outside of house; vision impairment contributing to with the caregiver and provided a report for the referring safety issues) physician that outlined treatment goals, therapy frequency, and Toileting and toilet hygiene (difficulty getting on and off duration. the toilet due to UE weakness and functional mobility The therapist chose a high-complexity evaluation code for problems) the following reasons: Health management (visual impairments contributing l An extensive additional review of physical and cognitive his- to difficulty with safe insulin administration; difficulty tory was needed related to current functional performance adjusting insulin levels) due to previous concussions identified in the history and l Clinical decision making was of moderate complexity due to profile. the need to analyze the detailed history, profile, and assess- l Five performance deficits were to be addressed in the plan of ments. Comorbidities (diabetes, retinopathy) were contrib- care due to his head injury: uting to his activity limitations. The client needed moderate Social participation (isolating behaviors limited socializa- assistance for transfers during the assessment. Several tion; impulsivity and mental rigidity negatively affected treatment options were considered. social relationships) CE-6 ARTICLE CODE CEA1216 DECEMBER 2016 l OT PRACTICE, 21(22) Earn.1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See below for details. Dressing (weakness, sensory deficits and left neglect, and poor sequencing led to difficulty manipulating clothing) Home management (lack of initiation of routines affected How to Apply for housekeeping and meal planning; left neglect, mem- ory loss, and diminished organizational skills impacted Continuing Education Credit performance) A. To get pricing information and to register to take the exam Safety and emergency maintenance (judgment impair- online for the article New Occupational Therapy Evalua- ment affected all ADLs) tion CPT® Codes: Coding Overview and Guidelines Health management and maintenance (pain interfered on Code Selection, go to www.aota.org/cea, or call toll-free with activity participation, client carry-over of tech- 877-404-2682. niques for compensating for memory loss, and initiation B. Once registered and payment received, you will receive instant strategies) email confirmation with password and access information to l Clinical decision making was of high complexity, as it take the exam online immediately or at a later time. included an analysis of data from a comprehensive history C. Answer the questions to the final exam found on page CE-8 by and profile, consideration of the impact of comorbidities December 31, 2018. (e.g., memory and sensory deficits), and consideration of D. On successful completion of the exam (a score of 75% or more), multiple treatment options. Significant modification was you will immediately receive your printable certificate. needed to complete assessments due to left-sided neglect and short-term memory loss. legally required that the therapist report the correct code for any RE-EVALUATION service provided. Re-evaluation: Reappraisal of the client’s performance and REFERENCES goals to determine the type and amount of change that American Medical Association. (2016). Current Procedural Terminology: CPT® has taken place. (AOTA, 2014, p. S45) 2017 Professional edition. Chicago: Author. As with the evaluation codes, a typical time is stated as 30 American Occupational Therapy Association. (2014). Occupational therapy minutes of face-to-face interaction with the client or family. practice framework: Domain and process (3rd ed.). American Journal of Occu- pational Therapy, 68, S1–S48. http://dx.doi.org/10.5014/ajot.2014.682006 Again, this is not to be considered a requirement or a limit on Baum, C. M., Connor, L. T., Morrison, T., Hahn, M., Dromerick, A. W., & time. Edwards, D. F. (2008). Reliability, validity, and clinical utility of the Execu- Although there are no levels of re-evaluation, the CPT tive Function Performance Test: A measure of executive function in a sample language provides similar guidance for the components of the of people with stoke. American Journal of Occupational Therapy, 62, 446–445. http://dx.doi.org/10.5014/ajot.62.4.446 reevaluation. CPT does not speak to when a re-evaluation can Kennedy, C. A., Beaton, D. E., Solway, S., McConnell, S., & Bombadier, C. take place; those guidelines are usually provided by payers. Pay- (2011). The DASH and QuickDASH Outcome Measure user’s manual (3rd ed.). ers such as Medicare and private insurance may have particular Toronto, ON, Canada: Institute for Work & Health. rules about when a re-evaluation is reimbursable. The CPT World Health Organization. (2001). International classification of functioning, language only describes the items required to bill the code. disability, and health. Geneva, Switzerland: Author. CONCLUSION The transition to these new codes may be challenging for thera- pists and administrators. But the codes are clear in their require- Final Exam ments. The components must be identified and justified in the Article Code CEA1216 documentation. Therapists must be clear with administrators that evaluation is a process not defined by the same amount of time or New Occupational Therapy Evaluation CPT® Codes: level for each client, but rather by the intensity and complexity of Coding Overview and Guidelines on Code Selection the client’s individual presenting problem and needs. Although the move to three levels of evaluation may seem December 19, 2016 daunting, the language of the CPT supports a holistic and broad To receive CE credit, exam must be completed by view of an occupational therapy evaluation. Proper use of the December 31, 2018. codes and appropriate identification of a level will create data to further show the breadth of occupational therapy practice. Learning Level: Intermediate While at the time of this writing Medicare may pay the same Target Audience: Occupational therapists and occupational therapy for each level, other payers may determine different payment assistants for each. Furthermore, as noted earlier, it is ethically and often Content Focus: Category 2: OT Process: Evaluation; Category 3: Professional Issues; Coding, Documentation DECEMBER 2016 l OT PRACTICE, 21(22) ARTICLE CODE CEA1216 CE-7  Continuing Education Article CE Article, exam, and certificate are also available ONLINE. Register at http://www.aota.org/cea or call toll-free 877-404-AOTA (2682). 1. The criteria used for choosing the correct evaluation 7. The identification of areas of performance deficits is level: defined in: A. Must be determined specifically for each of the three A. The CPT® Manual introductory language to the evalua- components tion codes B. Must all be at the same level for each component B. Descriptions in the Occupational Therapy Practice Frame- C. Must be rated high complexity if the clinical decision work: Domain and Process, 3rd Edition making is high C. Standards of Practice for Occupational Therapy D. Must reflect the moderate-complexity level if the therapist D. Only A and B cannot decide which level to bill 8. Clinical decision making: 2. The occupational profile contains all but which one of A. Is the most important of the three components the following components: B. Is a critical component in determining the level of the A. The client’s presenting problems and concerns evaluation B. The client’s desire for treatment techniques and a weekly C. Is rated moderate complexity if the data analyzed is from a visit schedule problem-focused assessment(s) C. The client’s priorities for outcomes D. Is not one of the three components in determining a D. The client’s occupational history and experiences, complexity level patterns of daily living, interests, values, and needs 9. Comorbidities are important to document because: 3. A key word in CPT® to consider when choosing a level A. They could affect participation restrictions or activity for an occupational profile and medical and therapy limitations. history is: B. They are identified as affecting client prognosis A. Basic determinations. B. Informal C. They are the sole factor in choosing a level. C. Brief D. They indicate the need for additional services. D. Concise 10. The new evaluation codes will go into effect: 4. The code descriptors are published annually by the A. January 1, 2017 American Medical Association in: B. After a grace period from January 1 to March 1, 2017 A. The Journal of the American Medical Association: JAMA C. July 1, 2017 CPT® 2017 D. After the AMA has completed education on the new B. Current Procedural Terminology: CPT® Professional Edition codes C. The Handbook of Insurance Coding: Coding Essentials® 2016 D. CMS Guidelines for Coding Manual: CMS Professional 11. The re-evaluation requirements include: Handbook A. A re-evaluation completed every 6 months B. An update to the initial occupational profile to reflect 5. The evaluation process and documentation are not changes in condition or environment that affect future intended to: interventions and goals A. Communicate occupational therapy’s distinct value to C. A formal re-evaluation when there is a documented others change in functional status, or a significant change to the B. Produce a static and sequential intervention plan plan of care is needed C. Show the breadth of concerns occupational therapy D. Only B and C considers D. Reflect the clinical work accomplished during the session 12. Which one of the following complexity components for clinical decision making should a therapist choose if the 6. The choice of a moderate-complexity level in the assess- evaluation required analysis of data from detailed assess- ment of occupational performance requires identifying: ments, consideration of several treatment options, and A. One to three performance deficits minimal to moderate modification of the assessments? B. Three to five performance deficits A. Low complexity C. Five or more performance deficits B. Moderate complexity D. None of the above C. High complexity D. None of the above CE-8 ARTICLE CODE CEA1216 DECEMBER 2016 l OT PRACTICE, 21(22)