More to Celebrate: New Evaluation Codes Recognize OT Clinical Decision Making; Now It’s Up to You!
The occupational therapy profession marked its 100th year with many achievements, including the establishment of new Current Procedural Terminology (CPT®) occupational therapy evaluation codes at the beginning of 2017. These new codes in particular are something to continue celebrating as we move into the future. For years, the American Medical Association (AMA) acknowledged the clinical decision making of physicians when creating the definitions and values of the CPT codes. Now, the clinical decision making that has always been part of the evaluation process of occupational therapy has been recognized by the AMA and included in the three CPT codes for evaluation.
Not only has clinical decision making been recognized, but it has been built in as an integral part of the new evaluation code language. As the next step, practitioners must recognize this opportunity and ensure that good clinical decision making is accomplished and documented in every evaluation. Practitioners have long employed learned competencies and use an internal “library” of information about clients and their needs. However, this hidden activity must now be brought to the forefront to be recognized as a skilled process. Further, occupational therapy practitioners must document all the elements of clinical decision making to inform payers and others. This process also works to justify the critical role of occupational therapy intervention with each client.
Although skilled practitioners often apply critical thinking imperceptibly during the evaluation process, it is now vital to make the “invisible” visible and understandable to payers and others. It is a critical component of how we promote the distinct value of occupational therapy, so it must be clearly evidenced in everyday practice and documentation. Clinical decision making matters, as does its clear, concise documentation.
The Code Language on Clinical Decision Making
The OT evaluation CPT codes include three components that must be completed prior to developing a plan of care. These are
- Occupational profile and history (both medical and therapy)
- Assessment of occupational performance (including identifying performance deficits addressed in the plan of care)
- Clinical decision making
These components are addressed at length in the AOTA article, “New Occupational Therapy Evaluation Coding Overview.”
The factors included in the AMA CPT code definitions that must be addressed and documented assist the OT practitioner with determining whether the clinical decision making is low, moderate, or high as required by the code language. The factors for clinical decision making include:
- Complexity or depth of the occupational profile/history
- Significance of comorbidities of the client
- Assessment modifications required to complete the evaluation
- Whether there are multiple or few treatment options that must be considered
The value placed on clinical decision making in the evaluation codes recognizes the skills and knowledge of the profession. The requirement to identify whether the clinical decision making is low, moderate, or high validates that practitioners must think and reason throughout the process, addressing and considering all the factors presented by the individual client. This reflects the intellectual work that practitioners do and that is paid for by the codes. The CPT code valuation process considers the work of qualified health care professionals, including the time, technical skill and effort, mental effort and judgment, and stress (resulting from possible consequences of the intervention for the client).
Specifying that an occupational therapy evaluation includes clinical decision making recognizes the occupational therapy practitioner’s work in identifying problems, determining appropriate interventions, and developing an effective plan of care. Practitioners must take this as a call to improve documentation of the occupational therapy process.
Elements of Clinical Decision Making in Occupational Therapy
As the profession’s guiding document, the Occupational Therapy Practice Framework: Domain & Process (Framework; American Occupational Therapy Association [AOTA], 2014) makes clear, the use of professional and clinical decision making “ensures the accurate selection and application of evaluations, interventions, and client-centered outcome measures” (p. S12). The new CPT codes for occupational therapy were established after much advocacy by AOTA. One of the victories is the recognition of the process of occupational therapy in which “practitioners use theoretical principles and models, knowledge about the effects of conditions on participation, and available evidence of the effectiveness of intervention to guide their reasoning” (AOTA 2014, p. S12). In adopting these codes, the AMA clearly delineates the distinct value of the OT practitioner and their ability to evaluate the entire client using professional judgment to establish a holistic plan of care.
Thus, it is critical for practitioners to understand the components of the evaluation process to identify the correct level of complexity, and to clearly document the decision making behind the level of complexity choice in the client’s medical record. Occupational therapy practitioners have the necessary skills and qualifications to conduct clinical decision making in all their evaluations and interventions. Schell (2003) describes clinical reasoning as, “the process used by practitioners to plan, direct, perform and reflect on client care” (p. 131). Robertson, Warrneder, and Barnard (2015) further explicate this process, stating:
Effective but effortful conscious reasoning and communication of reasoning, for example where a therapist decides to treat or not to treat, requires the therapist to juggle multiple frames of reference, data, theories and self-knowledge.” (p. 68)
How Do Practitioners Use this Opportunity?
Occupational therapy practitioners are the only professionals who can reiterate on a daily basis the full range of thought and analysis that goes into the occupational therapy process. Documentation should highlight the thinking and analysis that occurs as practitioners engage in evaluations. The code language provides guidance on what makes clinical decision making more or less complex and provides a framework for the evaluative process, but it is up to practitioners to state the depth and methods of occupational therapy critical thinking clearly and definitively.
Practitioners must document the “what and why” of the analysis of a client’s occupational therapy needs. Documenting this process is an opportunity to celebrate and announce to payers, claim reviewers, other professionals, supervisors, and managers the richness of the process by which occupational therapy practitioners come to conclusions—with the client—to determine needs and goals and the process to achieve them. The new CPT evaluation codes give the profession the template to demonstrate the profession’s perspective on meeting the occupational and functional needs of people and populations. Practitioners must use the knowledge and skills taught to them, reinforced in fieldwork, and mastered through daily practice to assure appropriate reimbursement for the services rendered. Further, the effective translation of the evaluation process into documentation will promote recognition of the need for and role of occupational therapy with each client.
Celebrating the value and perspective of occupational therapy can be done every time practitioners document clearly the thinking, analysis, and judgment that support optimum occupational therapy. It is a celebration that all practitioners can participate in every day to share the real and important thinking, analysis, and interpretation of occupational needs that undergird the profession and its distinct value.
References
- American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68, S1–S48. https://doi.org/10.5014/ajot.2014.682006
- Robertson, D., Warrneder, F., & Barnard, S. (2015). The critical occupational therapy practitioner: How to define expertise? Australian Occupational Therapy Journal, 62, 68–70. https://dog.org/10.1111/1440-1630.12157
- Schell, B. (2003). Clinical reasoning: The basis of practice. In B. Crepeau, E. Cohn, & B.A. B. Schell Eds.), Willard and Spackman’s occupational therapy, 6, 131. Philadelphia: Lippincott Williams & Watkins.