Therapy Evaluative Procedure Codes

 

PT Evaluative Procedures

Code Long Descriptor Short Descriptor
97161 Physical therapy evaluation: low complexity, requiring these components:
  • A history with no personal factors and/or comorbidities that impact the plan of care;
  • An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
  • A clinical presentation with stable and/or uncomplicated characteristics; and
  • Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
 PT Eval Low Complex 20 min
97162 Physical therapy evaluation: moderate complexity, requiring these components:
  • A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;
  • An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
  • An evolving clinical presentation with changing characteristics; and
  • Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
 PT Eval Mod Complex 30 min
97163 Physical therapy evaluation: high complexity, requiring these components:
  • A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care;
  • An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
  • A clinical presentation with unstable and unpredictable characteristics; and
  • Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
 PT Eval High Complex 45 min
97164 Re-evaluation of physical therapy established plan of care, requiring these components:
  • An examination including a review of history and use of standardized tests and measures is required; and
  • Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome.
 PT Re-eval Est Plan Care

 

OT Evaluative Procedures

Code Long Descriptor Short Descriptor
97165 Occupational therapy evaluation, low complexity, requiring these 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 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • 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. Patient 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.
 OT Eval Low Complex 30 min
97166 Occupational therapy evaluation, moderate complexity, requiring these 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 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • 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. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.
 OT Eval Mod Complex 45 min
97167 Occupational therapy evaluation, high complexity, requiring these 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) that identifies 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient 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 patient to complete evaluation component.
 OT Eval High Complex 60 min
97168 Re-evaluation of occupational therapy established plan of care, requiring these components:
  • An assessment of changes in patient 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 and/or goals; and
  • 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.
 OT Re-eval Est Plan Care

 

Last Updated Dec 09 , 2023