What are Performance Deficits in New OT Evaluation CPT® Codes?

New occupational therapy evaluation codes reflect the occupational focus of the profession. The new American Medical Association (AMA) Common Procedural Terminology (CPT®) 2017 manual identifies three levels of occupational therapy evaluation and one level of re-evaluation under the Physical Medicine and Rehabilitation (PM&R) section. The previous codes have been deleted, and occupational therapy evaluation and re-evaluation are now described by new codes with new requirements.

The code descriptor language follows the approach of the Occupational Therapy Practice Framework: Domain and Practice, 3rd Edition (Framework; American Occupational Therapy Association [AOTA], 2014) and presents a contemporary way to frame occupational therapy practice. A key element of the new code language is the focus on “performance deficits.” AOTA views the definition of performance deficits as support for an occupational focus for all occupational therapy evaluations and interventions.

Effective January 1, 2017, Medicare and most other third party payers (e.g., Medicaid, private insurers) began using these codes. Occupational therapists now need to identify and document criteria that distinguish low complexity (CPT® 97165), moderate complexity (CPT® 97166), and high complexity (CPT® 97167) evaluations, and re-evaluation (CPT® 97168). The code language describes each component of the evaluation: occupational profile and history (medical and therapy), assessments of occupational performance, clinical decision making, and development of the plan of care.

In addition to the other requirements of the codes, each of the three levels of evaluation complexity under the Assessment of Occupational Performance component requires a count of performance deficits. The CPT® introduction states that, “performance deficits refer to the inability to complete activities due to the lack of skills in one or more of the following categories (relating to physical, cognitive, or psychosocial skills)” (AMA, p. 666). AOTA analyzed the language in the context of best practice of occupational therapy and determined that a focus on the broadest interpretation of “performance deficits” was critical. Earlier discussions of the components of performance, such as client factors, performance patterns, and environment were too narrow and led away from a true occupational focus. Thus AOTA’s position is that performance deficits in the code language should be interpreted as occupations in which the client is experiencing problems and should be documented in the plan of care. Occupations are defined in the Framework in Table 1. This is consistent with the code descriptor language and the concepts emphasized during the development of the new code language. 

Performance deficits (occupations) can be identified from the list in the table below, but this list is not all inclusive. Defining deficits in the CPT® context is viewed as the process of identifying what areas of occupation(s) the plan of care will address. The therapist should consider all information gathered in the history and occupational profile to determine with the client the priority of performance deficits to be included. Ideally, the therapist will use standardized assessments to identify a baseline of performance skills from which intervention can begin. Standardized assessments, in combination with other assessment methods, can also be used to identify and document client factors, performance patterns, contexts, and environments that are contributing to activity limitations and/or performance restrictions in the occupation(s) identified.

As mentioned above, CPT® identifies performance skill categories and definitions as shown below, affirming critical areas of occupational therapy scope. A lack of performance skills contribute to the inability to complete occupations and relates to the Performance Skills described in Table 3 of the Framework. The definitions of physical, cognitive, and psychosocial skills from the CPT® introductory language are below.

It is important to understand that the number of performance deficits (occupations in which the client is having difficulty) is only one factor in assigning the level of code. The occupational profile and complexity of the history and clinical reasoning, which result in the development of the plan of care, must also be considered.

AOTA encourages practitioners to use the Framework as the basis of evaluation and occupation-based treatment to improve performance. The new CPT® introduction and code language identifies occupational performance, the occupational profile, and client needs and goals as essential to an occupational therapy evaluation. This language aligns with the Framework and encourages best-practice occupational therapy evaluations.

References

American Medical Association. (2016). Current Procedural Terminology: CPT® 2017 professional edition. Chicago: Author. Current Procedural Terminology is copyright 1965, 1970, 1973, 1977, 1981, 1983–2016 by the American Medical Association. All rights reserved.

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3^rd ed.). (2014). American Journal of Occupational Therapy, 68, S1–S48. http://dx.doi.org/10.5014/ajot.2014.682006