How To Use CPT Code 97165

CPT 97165 is an occupational therapy evaluation code for low complexity patients, covering topics such as the procedure, qualifying circumstances, documentation requirements, billing guidelines, and more.

1. What is CPT 97165?

CPT 97165 is a code used by medical professionals to bill for an occupational therapy evaluation of low complexity. This evaluation assesses a patient’s ability to perform daily activities related to work, home, play, and other aspects of their general lifestyle. The code is used when the patient presents with no comorbidities that affect occupational performance and the evaluation components can be completed without modification of tasks or assistance.

2. 97165 CPT code description

The official description of CPT code 97165 is: “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 (ie, 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 (eg, 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 patient and/or family.”

3. Procedure

The 97165 procedure involves the following steps:

1. Review of the patient’s occupational profile and medical and therapy history, including records related to the presenting problem.
2. Assessment of 1-3 performance deficits (physical, cognitive, or psychosocial) that result in activity limitations and/or participation restrictions.
3. Clinical decision making of low complexity, including analysis of the occupational profile, problem-focused assessment data, and consideration of a limited number of treatment options.
4. Completion of the evaluation without the need for task modification or assistance (physical or verbal).
5. Typically, 30 minutes of face-to-face time with the patient and/or family.

4. Qualifying circumstances

Patients eligible to receive CPT code 97165 services are those who:

• Require an occupational therapy evaluation of low complexity.
• Present with no comorbidities that affect occupational performance.
• Do not require task modification or assistance (physical or verbal) to complete the evaluation components.

5. When to use CPT code 97165

It is appropriate to bill the 97165 CPT code when an occupational therapist performs an initial evaluation of low complexity to assess the patient’s ability to carry out activities related to their work, home, play, and other parts of a general lifestyle. The evaluation should include the components outlined in the official description and be completed without the need for task modification or assistance.

6. Documentation requirements

To support a claim for CPT 97165, the following information should be documented:

• Patient’s occupational profile and medical and therapy history, including records related to the presenting problem.
• Assessment of 1-3 performance deficits (physical, cognitive, or psychosocial) that result in activity limitations and/or participation restrictions.
• Clinical decision making of low complexity, including analysis of the occupational profile, problem-focused assessment data, and consideration of a limited number of treatment options.
• Confirmation that the evaluation components were completed without the need for task modification or assistance (physical or verbal).
• Face-to-face time spent with the patient and/or family (typically 30 minutes).

7. Billing guidelines

When billing for CPT code 97165, keep in mind the following guidelines and tips:

• Ensure that the patient meets the qualifying circumstances for a low complexity occupational therapy evaluation.
• Document all required information to support the claim, as outlined in the documentation requirements section.
• Be aware of similar codes for moderate and high complexity occupational therapy evaluations (97166 and 97167) and occupational therapy re-evaluation (97168) to ensure accurate billing.

8. Historical information

CPT 97165 was added to the Current Procedural Terminology system on January 1, 2017. There have been no updates since its addition.

9. Similar codes to CPT 97165

Five similar codes to CPT 97165 and how they differentiate are:

• CPT 97166: Occupational therapy evaluation of moderate complexity, with more performance deficits and clinical decision making of moderate complexity.
• CPT 97167: Occupational therapy evaluation of high complexity, with even more performance deficits and clinical decision making of high complexity.
• CPT 97168: Occupational therapy re-evaluation, used when a patient requires a re-assessment after an initial evaluation.
• CPT 97169: Athletic training evaluation, low complexity, for assessing an athlete’s ability to participate in sports and physical activities.
• CPT 97170: Athletic training evaluation, moderate complexity, for a more in-depth assessment of an athlete’s ability to participate in sports and physical activities.

10. Examples

Here are 10 detailed examples of CPT code 97165 procedures:

1. An occupational therapist evaluates a patient with mild arthritis in their hands, affecting their ability to perform daily tasks such as buttoning clothes or opening jars.
2. A patient recovering from a minor stroke undergoes an occupational therapy evaluation to assess their ability to return to work and perform daily activities.
3. An individual with a recent diagnosis of carpal tunnel syndrome receives an occupational therapy evaluation to determine the impact on their daily activities and work performance.
4. A patient with a mild cognitive impairment undergoes an occupational therapy evaluation to assess their ability to manage daily tasks such as meal preparation and medication management.
5. An occupational therapist evaluates a patient with a recent hip replacement to determine their ability to perform daily activities such as dressing and bathing independently.
6. A patient with a history of anxiety and depression receives an occupational therapy evaluation to assess their ability to participate in social and leisure activities.
7. An individual with a recent diagnosis of multiple sclerosis undergoes an occupational therapy evaluation to determine the impact on their daily activities and work performance.
8. A patient recovering from a minor traumatic brain injury receives an occupational therapy evaluation to assess their ability to return to work and perform daily activities.
9. An occupational therapist evaluates a patient with a recent diagnosis of Parkinson’s disease to determine the impact on their daily activities and work performance.
10. A patient with a history of chronic pain undergoes an occupational therapy evaluation to assess their ability to manage daily tasks such as household chores and self-care activities.