Evaluate Your OT and PT Coding



These services may seem alike, but differences in requirements can make or break your code assignment.

Physical therapy (PT) and occupational therapy (OT) evaluations are similar, but like the two disciplines themselves, there are some distinct differences. Both include four components that must be performed and documented to meet the requirements for a particular level of service. But where they part ways is the actual component requirements. Medical coders must understand these differences for proper coding of these services.

Physical Therapy Evaluation Guidelines

PT evaluations focus on standardized measurements, use clinical presentation as a measure of complexity, and focus on activity limitations, participation restrictions, and body functions.

History components include personal factors such as sex, age, coping style, social background, education, and profession and comorbidities such as other medical conditions that directly impact the plan of care. This can include the overall behavior pattern, character, and other factors that influence how disability is experienced by the individual.

Examination components include body structures and functions (classified by body systems) which are broken down as follows:

  • Body regions: head, neck, back, upper extremity, lower extremity, trunk
  • Body systems: musculoskeletal, neuromuscular, cardiovascular, pulmonary, integumentary
  • The American Physical Therapy Association (APTA) provides a detailed breakdown of assessments for each body system.

Examination also includes activity limitations, such as reported difficulty in performing any task, or activity and participation restrictions such as reported issues that limit interaction in work or social events. When considering the elements included in the PT evaluation, the number of body structures should be based on the degree or extent of the examination. For example, the examination may involve an entire limb, a joint, or a specific area of the spine. It is the therapist’s responsibility to define and document the specific structure(s) examined.

As shown in Table A, clinical decision making includes clinical presentation or severity of the patient’s condition. Low complexity includes a stable or uncomplicated clinical presentation; moderate complexity requires changing characteristics; and high complexity includes unstable or unpredictable clinical presentation. Determination of complexity is made using standardized assessment tools or measurable functional outcomes.

Although typical time is listed for the evaluation codes, unlike office and outpatient evaluation and management (E/M) services, time cannot be used as a factor in determining the level of service. A plan of care must also be completed.

Occupational Therapy Evaluation Guidelines

OT evaluations require occupational profile/history, performance deficits, and clinical decision making. Development of a plan of care is also required. To bill an evaluation code, you must meet the requirements of all four components of the code.

An occupational profile is required for every evaluation and is adapted directly from the Occupational Therapy Practice Framework. It is the starting point to determine what treatment is needed. An occupational profile should include the patient’s occupational history, concerns, reasons for referral, and the patient’s goals. History includes reviews of related medical conditions and previous therapy history.

The three levels of the occupational profile and history components are broken down into brief, expanded, and extensive:

  • Brief looks at the presenting problem alone.
  • Expanded and extensive also consider related physical, cognitive, and psychosocial performance and therapy history.
  • Extensive differs from expanded in the amount of information documented and the number, length, and severity of comorbidities.

The second component, performance deficits, has caused some confusion regarding whether the assessment should be occupations or performance skills where there are challenges. The American Occupational Therapy Association (AOTA) states that performance deficits should be considered occupations. A complete list of occupations can be found in the Occupational Therapy Practice Framework.

This process does not discount performance skills deficits; rather, the skills should be outlined in terms of the occupation that is affected. Keep in mind, this process is being performed as a means of determining what occupations will be addressed in the plan of care, so everything should be reviewed using that context. A low complexity evaluation examines 1-3 deficits, moderate 3-5 deficits, and high 5 or more deficits.

Clinical decision making is generally the hardest component for practitioners to grasp because there is a subjective component to it. It requires use of clinical judgment in determining whether the complexity is low, moderate, or high. That judgment must be justified in the documentation.

As shown in Table B, low complexity generally is an analysis of a problem-focused assessment with limited treatment options and no comorbidities. Moderate complexity includes analysis of a detailed assessment with several treatment options and possibly comorbidities. Some modification of tasks may be required to complete the evaluation. High complexity includes analysis of a comprehensive assessment with multiple treatment options and comorbidities affecting performance. Significant modification of tasks is required to complete the evaluation. Modification refers to any assistance the occupational therapist must provide to the patient to complete the evaluation. This can include verbal cues or physical assistance.

Don’t Forget the Plan of Care

Every PT and OT evaluation requires a plan of care. Without a plan of care, an evaluation cannot be billed. Evaluations are face-to-face services. Even if it takes multiple days to complete, an evaluation can only be billed once. Bill the evaluation on the date it is completed.

PT and OT evaluations are untimed codes. Even though the descriptions include typical time, unlike office and outpatient E/M billing, there is not a circumstance where time can be used to determine level of service. Interventions can be billed on the same day of the evaluation provided the plan of care is completed prior to the intervention. The intervention must be based on the plan of care. It cannot be billed if it is used to complete the evaluation.

Medicare continues to reimburse all three levels of evaluation codes at the same rate. The Centers for Medicare & Medicaid Services (CMS) has indicated it will review code usage to determine payment stratification, so it is very important that the level of complexity billed matches the documentation.

The requirements for a reevaluation include an assessment of changes in patient functional or medical status; an update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and a revised plan of care. The requirements go on to specify that a formal reevaluation is only performed when there is a documented change in functional status or a significant change to the plan of care is required. Without meeting these requirements, a progress note may still be required, but a reevaluation cannot be billed.

For additional questions, please reach out to AOTA at [email protected] or APTA at [email protected]

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