What are performance deficits in the OT evaluation CPT® codes?

Occupational therapy evaluation codes reflect the occupational focus of the profession. The new American Medical Association (AMA) Common Procedural Terminology (CPT®) manual identifies three levels of occupational therapy evaluation and one level of re-evaluation under the Physical Medicine and Rehabilitation (PM&R) section.

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 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.

Physical

Physical skills refer to body structure or body function (e.g., balance, mobility, strength, endurance, fine or gross motor coordination, sensation, dexterity).

Cognitive

Cognitive skills refer to the ability to attend, perceive, think, understand, problem solve, mentally sequence, learn, and remember, resulting in the ability to organize occupational performance in a timely and safe manner. These skills are observed when a person (1) attends to and selects, interacts with, and uses task tools and materials; (2) carries out individual actions and steps; and (3) modifies performance when problems are encountered.

Psychosocial

Psychosocial skills refer to interpersonal interactions, habits, routines and behaviors; active use of coping strategies; and or environmental adaptations to develop skills necessary to successfully and appropriately participate in everyday tasks and social situations.

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 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 Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001