How To Use CPT Code 97166

CPT 97166 is an occupational therapy evaluation code for moderate complexity, covering the evaluation process, qualifying circumstances, documentation requirements, billing guidelines, and more.

1. What is CPT 97166?

CPT 97166 is a code used by medical professionals to bill for occupational therapy evaluations of moderate complexity. This code is specifically designed for patients who require an assessment of their physical, cognitive, or psychosocial skills to identify performance deficits that result in activity limitations and/or participation restrictions. The evaluation process includes an occupational profile, medical and therapy history, and clinical decision-making of moderate analytic complexity.

2. 97166 CPT code description

The official description of CPT code 97166 is: “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 (ie, 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 (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family.”

3. Procedure

1. Review the patient’s occupational profile and medical and therapy history, including an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.
2. Conduct an assessment(s) to identify 3-5 performance deficits (relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.
3. Engage in 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.
4. Provide minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) to enable the patient to complete the evaluation component.
5. Spend typically 45 minutes face-to-face with the patient and/or family during the evaluation process.

4. Qualifying circumstances

Patients eligible to receive CPT code 97166 services are those who present with comorbidities that affect their occupational performance and require an evaluation of moderate complexity. These patients may have limitations in their physical, cognitive, or psychosocial skills that result in activity limitations and/or participation restrictions. The evaluation process should be tailored to the patient’s specific needs and may require minimal to moderate modification of tasks or assistance to enable the patient to complete the evaluation component.

5. When to use CPT code 97166

It is appropriate to bill the 97166 CPT code when an occupational therapist performs an evaluation of moderate complexity on a patient who presents with comorbidities that affect their occupational performance. The evaluation should include an occupational profile, medical and therapy history, assessment of performance deficits, and clinical decision-making of moderate analytic complexity. The therapist should spend typically 45 minutes face-to-face with the patient and/or family during the evaluation process.

6. Documentation requirements

To support a claim for CPT 97166, the following information should be documented:

• Patient’s occupational profile and medical and therapy history, including an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance.
• Assessment(s) conducted to identify 3-5 performance deficits (relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions.
• Clinical decision-making of moderate analytic complexity, including an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options.
• Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) provided with assessment(s) to enable the patient to complete the evaluation component.
• Duration of face-to-face time spent with the patient and/or family during the evaluation process (typically 45 minutes).

7. Billing guidelines

When billing for CPT code 97166, it is essential to follow the appropriate billing guidelines and rules. Ensure that the patient meets the qualifying circumstances for this code and that the necessary documentation requirements are met. Additionally, be aware of any specific payer policies or requirements that may apply to the billing of this code. It is also important to be familiar with similar codes, such as CPT 97165 and CPT 97167 for occupational therapy evaluations of low and high complexity, respectively, and CPT 97168 for occupational therapy re-evaluation.

8. Historical information

CPT 97166 was added to the Current Procedural Terminology system on January 1, 2017. There have been no updates to this code since its addition.

9. Similar codes to CPT 97166

Five similar codes to CPT 97166 and how they differentiate from CPT 97166 are:

1. CPT 97165: Occupational therapy evaluation of low complexity.
2. CPT 97167: Occupational therapy evaluation of high complexity.
3. CPT 97168: Occupational therapy re-evaluation.
4. CPT 97169: Athletic training evaluation, low complexity.
5. CPT 97170: Athletic training evaluation, moderate complexity.

10. Examples

Here are 10 detailed examples of CPT code 97166 procedures:

1. An occupational therapist evaluates a patient with rheumatoid arthritis, assessing their physical, cognitive, and psychosocial skills to identify performance deficits that result in activity limitations and/or participation restrictions.
2. A patient recovering from a stroke undergoes a moderate complexity occupational therapy evaluation to assess their ability to perform activities of daily living and identify any necessary modifications or assistance.
3. An individual with a traumatic brain injury receives a CPT 97166 evaluation to assess their cognitive and psychosocial skills, as well as any physical limitations that may impact their ability to participate in daily activities.
4. A patient with multiple sclerosis undergoes a moderate complexity occupational therapy evaluation to determine the impact of their condition on their occupational performance and identify any necessary modifications or assistance.
5. An occupational therapist evaluates a patient with a spinal cord injury, assessing their physical, cognitive, and psychosocial skills to identify performance deficits that result in activity limitations and/or participation restrictions.
6. A patient with a recent amputation receives a CPT 97166 evaluation to assess their ability to perform activities of daily living and identify any necessary modifications or assistance.
7. An individual with Parkinson’s disease undergoes a moderate complexity occupational therapy evaluation to determine the impact of their condition on their occupational performance and identify any necessary modifications or assistance.
8. A patient with a cognitive impairment receives a CPT 97166 evaluation to assess their cognitive and psychosocial skills, as well as any physical limitations that may impact their ability to participate in daily activities.
9. An occupational therapist evaluates a patient with a chronic pain condition, assessing their physical, cognitive, and psychosocial skills to identify performance deficits that result in activity limitations and/or participation restrictions.
10. A patient with a developmental disability undergoes a moderate complexity occupational therapy evaluation to determine the impact of their condition on their occupational performance and identify any necessary modifications or assistance.