Finding the Right CPT Code for OT Evaluation
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Looking for the correct CPT code for OT evaluation? This article shares CPT codes, including how to choose the correct OT eval CPT code.
Occupational therapists (OTs) use Current Procedural Terminology (CPT) codes in their everyday practice.
CPT codes are a uniform way of reporting medical procedures and services for administrative management and insurance claims.
Bookmark this article, as it can be helpful for when you need to find a particular CPT code for OT evaluation or CPT code for occupational therapy treatment.
What are CPT codes and how do OTs use them?
CPT codes are mainly used as medical billing codes to process insurance claims and seek reimbursement.
These codes were developed over 50 years ago by the American Medical Association (AMA) and are updated yearly. The codes, which are used by most healthcare providers around the United States, are typically 5-digit codes.
OTs use CPT codes for OT evaluation and treatment. The American Occupational Therapy Association also maintains an updated list of CPT codes for OTs.
When OTs see a client, they will use CPT codes to “describe” to insurance companies what occurred during the client’s session.
CPT codes are used to document every aspect of treatment, including evaluation. Multiple codes can be used per session to accurately reflect what was done.
Each CPT code has a description of that particular code and many indicate a specified amount of time. For example, CPT code 97530 is for therapeutic activities. This is described as direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
CPT codes are updated annually to help healthcare providers keep up with the latest changes and codes. Recently, codes for teletherapy and COVID-19 have been added, which many OT practitioners may find helpful.
If you are new to CPT codes and billing, you may wonder about the difference between CPT and ICD-10 codes. Both are used for medical billing, but ICD-10 codes are used to classify diseases, while CPT codes describe treatments and procedures.
CPT codes for occupational therapy evaluation
There are four CPT codes for OT evaluation.
The OT eval CPT codes include:
- 97165: Occupational therapy evaluation, low complexity (30 minutes)
- 97166: Occupational therapy evaluation, moderate complexity (45 minutes)
- 97167: Occupational therapy evaluation, high complexity (60 minutes)
- 97168: Occupational therapy re-evaluation (30 minutes)
Each OT eval CPT code has specific guidelines. Familiarizing yourself with the codes and their requirements is important so you can properly bill for the services you have provided.
The following section will examine these specific requirements in more detail, including a chart to help guide your decision-making.
How to choose the right CPT code for OT evaluation
Determining the correct OT eval CPT code to use is dependent on the specifics of the evaluation and the amount of time you spend evaluating your client. This is based on the complexity of your client’s condition, as well as the complexity of the evaluation.
Note: All evaluations must include a client history, an occupational profile, the development of a plan of care, and a review of records.
The chart below shows the specific guidelines for each CPT code to help you choose the correct one:
| CPT Code | Level of Complexity | # of Performance Deficits* (physical, cognitive, psychosocial) | Modification of Tasks During Evaluation |
| 97165 | low | 1-3 | none |
| 97166 | moderate | 3-5 | minimal to moderate |
| 97167 | high | 5 or more | maximal |
| 97168 | reevaluation | — | — |
*Performance deficits are defined as a lack of skill in cognitive, psychosocial, or physical skills, which leads to an inability to complete activities.
Physical skills are physical (body) impairments, such as strength, endurance, balance, or fine and gross motor coordination.
Psychosocial skills are behaviors, habits, or routines that allow a person to participate in social activities or regular everyday tasks. Treatment involves coping strategies or adaptations.
Cognitive skills are the skills needed to perform actions, make modifications if there are problems, and interact with things like materials in a safe and timely way. This also includes being able to sequence steps and problem-solve.
Occupational therapy treatment CPT codes
There are also CPT codes for occupational therapy treatment. These codes are often (but not always) billed in 15-minute increments.
It is important to note that not all CPT codes are accepted by all insurance companies.
Consequently, whenever possible, check with your client's insurance company to find out which CPT codes they accept.
For OTs, there are various treatment categories and codes to choose from, including CPT codes for remote management. Appropriate documentation when using CPT codes is important to ensure claims are processed and reimbursed accordingly.
There are over 10,000 CPT codes. While that may seem overwhelming, it is generally easy to find the most appropriate code.
Some common CPT codes for OT treatment include:
- 97110: Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, and flexibility
- 97129: Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes
- 97113: Aquatic therapy with therapeutic exercises
- 97116: Gait training (includes stair climbing)
- 97124: Massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion)
Using CPT codes in your practice
CPT codes provide a uniform understanding of what occurred during an OT session for reimbursement and management purposes.
CPT codes for OTevaluation are classified in order of complexity of your patient's needs. The specific guidelines and descriptions under each OT eval CPT code can help you choose the most appropriate code for your services.
Familiarizing yourself with CPT codes for evaluation and treatment is an important part of running your practice.
Understanding these codes can save you time and help insurance companies and other medical professionals understand your treatment and services.
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