What CPT codes are used for occupational therapy evaluation?

OT evaluations use: 97165 (low complexity - 1-3 performance deficits, brief history, minimal/no clinical decision-making), 97166 (moderate complexity - 3-5 deficits, expanded history, moderate decision-making), 97167 (high complexity - 5+ deficits, comprehensive history, high decision-making with comorbidities). Re-evaluation uses 97168. Select based on complexity of clinical presentation and decision-making required.

What documentation is required for skilled OT services?

Document: patient's diagnosis and functional limitations, prior level of function, objective assessment findings (ROM, strength, sensation, coordination, ADL/IADL status with assist levels), clinical reasoning demonstrating skilled OT need, specific measurable goals (SMART format), treatment plan frequency/duration, and expected outcomes. Documentation must show why services require OT expertise.

How should ADL assessment be documented for coverage?

Document each ADL (feeding, grooming, dressing upper/lower, bathing, toileting, transfers) with specific assist level using standard terminology: Independent, Supervision, Minimal Assist (25%), Moderate Assist (50%), Maximum Assist (75%), or Dependent. Include specific deficits affecting performance (weakness, coordination, cognition), safety concerns, and adaptive equipment needs.

What makes OT services skilled versus unskilled?

Skilled OT requires professional judgment for: complex patient presentation, active treatment progression, functional improvement potential, specialized techniques (neurodevelopmental treatment, manual therapy, cognitive retraining), and patient/caregiver training. Document clinical reasoning for interventions. Maintenance programs without improvement potential may transition to home exercise or caregiver-provided care.

How should OT goals be written to meet payer requirements?

Goals must be SMART: Specific (name activity), Measurable (quantify assist level, repetitions, accuracy), Achievable (realistic for patient), Relevant (functional outcome), Time-bound (target date). Example: 'Patient will don shirt with min assist in 2 weeks' or 'Patient will demonstrate safe meal prep with supervision in 3 weeks.' Include both short-term and long-term goals with clear functional outcomes.

Occupational Therapy Evaluation Template (OT)

Quick-Use Checklist

Use this checklist before finalizing documentation.

Confirm visit context, chief concern, and date/time of service before note completion.

Capture required exam/findings and plan elements that support coding specificity.

Document medical decision making clearly to reduce denials and audit risk.

Subjective

Chief Complaint: [Patient's main concern/reason for referral] HPI: [History of present illness/injury, date of onset, prior level of function] Home Environment: [Stairs, rails, equipment, rugs, assistance available] Medical History: [Relevant PMH]

Objective

Mental Status: [Alert, oriented, direction following] Upper Extremity ROM/Strength:

* Right: [Shoulder, Elbow, Wrist, Hand limits/strength]
* Left: [Shoulder, Elbow, Wrist, Hand limits/strength]

Sensation: [Light touch, sharp/dull, proprioception] Coordination: [Fine motor, gross motor] Vision/Perception: [Visual fields, neglect, tracking] ADL Assessment (Level of Assist):

* Feeding: [Indep/Supervision/Min/Mod/Max/Dep]
* Grooming: [Indep/Supervision/Min/Mod/Max/Dep]
* Dressing (Upper): [Indep/Supervision/Min/Mod/Max/Dep]
* Dressing (Lower): [Indep/Supervision/Min/Mod/Max/Dep]
* Bathing: [Indep/Supervision/Min/Mod/Max/Dep]
* Toileting: [Indep/Supervision/Min/Mod/Max/Dep]
* Transfers: [Indep/Supervision/Min/Mod/Max/Dep]

IADLs: [Meal prep, money management, medication management]

Assessment

Functional Deficits: Patient demonstrates deficits in [list deficits] affecting ability to perform [ADLs/IADLs]. Rehab Potential: [Excellent/Good/Fair/Poor] based on [rationale]. Clinical Impression: Patient [is/is not] a candidate for skilled OT services to address [impairments].

Plan

Frequency: [x] times per week for [x] weeks. Goals (Short Term - 2 weeks):

1. Patient will perform [activity] with [level of assist] to improve independence.
2. Patient will increase [ROM/Strength] to [measure] to facilitate [functional task].

Goals (Long Term - 4 weeks):

1. Patient will be Independent with [ADL].
2. Patient will demonstrate [safety technique] 100% of the time.

Interventions: [Therapeutic exercise, ADL training, Neuro re-ed, Manual therapy]

Occupational Therapy — Initial Evaluation Template

Quick-Use Checklist

Template

Subjective

Objective

Assessment

Plan

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