Update: How OT Practitioners Utilize Evaluation Codes

In January 2017, three new occupational therapy Current Procedural Terminology (CPT®) evaluation codes (97165, 97166, and 97167) were introduced under the Physical Medicine and Rehabilitation (PM&R) section of the CPT Manual. These new codes are a major victory for occupational therapy (OT) practitioners as they introduce a paradigm for evaluations based on patient complexity (low, moderate, or high) and specify that physical, cognitive, and psychosocial functional issues can be assessed as part of an OT evaluation.

Despite AOTA’s advocacy for stratified relative value unit (RVU) values for each code based on complexity level, CMS finalized a work RVU of 1.20 for each of the OT evaluation CPT codes because of concerns of potential abuses and budget neutrality. The work RVU is one of three components that determines the full price of CPT codes based on the work of the therapist and includes the time to perform the service, technical skill and physical effort, required mental effort and judgment, and stress related to potential risk. The AMA rules for determining work values focus only on Medicare Part B services and are not all inclusive of Part B settings where many OT practitioners work, such as Medicare SNF Part B therapy billing.

Based on the analysis of the available Part B database data for proposing stratified RVU values for the codes, AOTA estimated an evaluation frequency of 50% for low complexity evaluations, 40% for moderate complexity evaluations, and 10% for high complexity evaluations. Although CMS chose not to stratify reimbursement by level of complexity in 2017, it indicated that it would collect data on OT utilization of the codes to confirm AOTA’s proposed utilization percentages and revisit applying stratified values to the OT evaluation codes at a later time. 

Early indications based on available Medicare Part B data used for RVU development indicate that AOTA’s predicted utilization values were correct. AOTA’s evaluation frequency for 2017 is 52% low complexity, 38% moderate complexity, and 10% high complexity. These results fall squarely within the 50%, 40%, and 10% (low, moderate, and high) estimates AOTA proposed to CMS. 

These results are due to the hard work of OT practitioners arming themselves with the necessary knowledge through a comprehensive AOTA educational campaign, which included online webinars; in-person trainings at various national, state, and specialty OT conferences; and AOTA-published articles and FAQs. AOTA members continue to be provided with detailed information about components of the codes and how to interpret, document, and identify the correct complexity levels of the evaluation codes in their daily practice. Ultimately, AOTA believes that accurate utilization data will result in CMS considering stratified evaluation code payment values in the future.

For more information on the occupational therapy evaluation codes and other important coding resources, please visit the AOTA Coding and Billing webpage at the link below.

https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Coding.aspx