How To Use CPT Code 97167

CPT 97167 is a high complexity occupational therapy evaluation code, covering topics such as the evaluation process, qualifying circumstances, documentation requirements, billing guidelines, and more.

1. What is CPT 97167?

CPT 97167 is a code used to represent a high complexity occupational therapy evaluation. Occupational therapists use this code when performing a comprehensive evaluation of a patient’s physical, cognitive, and psychosocial abilities, which requires a high level of clinical decision-making and analysis. This code is specifically used for patients with multiple comorbidities that affect their occupational performance and require significant modifications or assistance during the evaluation process.

2. 97167 CPT code description

The official description of CPT code 97167 is: “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 (ie, 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 (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 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 medical and therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance.
2. Conduct a comprehensive assessment to identify 5 or more performance deficits (physical, cognitive, or psychosocial) that result in activity limitations and/or participation restrictions.
3. Engage in clinical decision-making of high analytic complexity, including analysis of the patient profile, data from the comprehensive assessment, and consideration of multiple treatment options.
4. Address the patient’s comorbidities that affect occupational performance and provide significant modification of tasks or assistance (physical or verbal) as needed during the assessment.
5. Spend approximately 60 minutes face-to-face with the patient and/or family during the evaluation process.

4. Qualifying circumstances

Patients eligible to receive CPT code 97167 services are those who present with multiple comorbidities that significantly impact their occupational performance. These patients require a high complexity evaluation due to the presence of five or more performance deficits in physical, cognitive, or psychosocial skills, resulting in activity limitations and/or participation restrictions. Additionally, these patients necessitate significant modifications or assistance during the evaluation process, such as physical or verbal support, to complete the assessment components.

5. When to use CPT code 97167

It is appropriate to bill CPT code 97167 when an occupational therapist performs a high complexity evaluation on a patient with multiple comorbidities that affect their occupational performance. This evaluation should include a comprehensive assessment of the patient’s physical, cognitive, and psychosocial abilities, requiring a high level of clinical decision-making and analysis. The therapist must also provide significant modifications or assistance during the evaluation process to enable the patient to complete the assessment components.

6. Documentation requirements

To support a claim for CPT 97167, the following information should be documented:

• A detailed occupational profile and medical and therapy history, including a review of medical and therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance.
• Results of the comprehensive assessment, identifying 5 or more performance deficits (physical, cognitive, or psychosocial) that result in activity limitations and/or participation restrictions.
• Evidence of clinical decision-making of high analytic complexity, including analysis of the patient profile, data from the comprehensive assessment, and consideration of multiple treatment options.
• Documentation of the patient’s comorbidities that affect occupational performance and the significant modifications or assistance provided during the assessment process.
• Record of the time spent face-to-face with the patient and/or family during the evaluation, typically 60 minutes.

7. Billing guidelines

When billing for CPT code 97167, it is essential to ensure that the evaluation meets the criteria for high complexity, including the presence of multiple comorbidities, significant performance deficits, and the need for significant modifications or assistance during the assessment process. Additionally, the documentation should clearly support the claim, providing evidence of the comprehensive evaluation and clinical decision-making involved. It is also important to be aware of any payer-specific guidelines or requirements related to billing for occupational therapy evaluations.

8. Historical information

CPT 97167 was added to the Current Procedural Terminology system on January 1, 2017. There have been no updates to the code since its addition.

9. Similar codes to CPT 97167

Five similar codes to CPT 97167 include:

1. CPT 97165: Occupational therapy evaluation of low complexity, focusing on fewer performance deficits and requiring less clinical decision-making.
2. CPT 97166: Occupational therapy evaluation of moderate complexity, addressing a moderate number of performance deficits and requiring moderate clinical decision-making.
3. CPT 97168: Occupational therapy re-evaluation, used when reassessing a patient’s progress and updating the treatment plan as needed.
4. CPT 97110: Therapeutic procedure, focusing on specific exercises to develop strength, endurance, range of motion, and flexibility.
5. CPT 97530: Therapeutic activities, involving the use of dynamic activities to improve functional performance.

10. Examples

Here are 10 detailed examples of CPT code 97167 procedures:

1. An occupational therapist evaluates a patient with multiple sclerosis, assessing their physical, cognitive, and psychosocial abilities to determine the impact on their daily activities and participation in social roles.
2. A patient with a traumatic brain injury undergoes a high complexity occupational therapy evaluation to identify performance deficits and develop a comprehensive treatment plan.
3. An individual with Parkinson’s disease receives a CPT 97167 evaluation to assess their ability to perform activities of daily living and determine appropriate interventions to maintain independence.
4. A patient with a spinal cord injury is evaluated using CPT code 97167 to assess their upper extremity function, mobility, and self-care abilities, as well as their cognitive and psychosocial well-being.
5. An occupational therapist performs a high complexity evaluation on a patient with a recent stroke, identifying performance deficits in motor control, cognition, and communication that impact their ability to participate in daily activities.
6. A patient with a history of chronic pain and depression undergoes a CPT 97167 evaluation to assess their physical and psychosocial abilities and develop a comprehensive pain management plan.
7. An individual with a progressive neurological disorder receives a high complexity occupational therapy evaluation to determine their current functional abilities and identify appropriate interventions to maintain their quality of life.
8. A patient with a recent amputation is evaluated using CPT code 97167 to assess their ability to perform self-care tasks, mobility, and participation in social roles, as well as to determine the need for prosthetic training and other interventions.
9. An occupational therapist performs a high complexity evaluation on a patient with a complex medical history, including diabetes, arthritis, and cognitive decline, to assess their ability to manage their daily activities and maintain their independence.
10. A patient with a history of substance abuse and mental health issues undergoes a CPT 97167 evaluation to assess their cognitive, emotional, and psychosocial abilities and develop a comprehensive treatment plan to support their recovery and reintegration into the community.