CPT code 97165 is used to describe the initial evaluation performed by an occupational therapist. This evaluation is crucial for establishing a baseline of the patient’s current functional abilities, identifying their needs, setting therapeutic goals, and developing a comprehensive treatment plan. The evaluation typically involves assessing the patient’s medical history, physical, cognitive, and psychosocial status, as well as their functional performance in daily activities.
Here are three examples of situations where an occupational therapist may use CPT 97165 for billing:
- Post-stroke rehabilitation: A patient who recently experienced a stroke and is referred to an occupational therapist for an initial evaluation. The therapist will assess the patient’s motor skills, coordination, cognitive abilities, and overall functional performance to determine the most appropriate interventions for their recovery and reintegration into daily life.
- Pediatric evaluation: A child with developmental delays or a diagnosed condition, such as autism spectrum disorder, is referred to an occupational therapist for an initial evaluation. The therapist will assess the child’s fine and gross motor skills, sensory processing, social-emotional development, and functional performance in school and home environments to create a tailored treatment plan.
- Workplace injury: An employee who has sustained a work-related injury, such as carpal tunnel syndrome or a repetitive stress injury, is referred to an occupational therapist for an initial evaluation. The therapist will assess the employee’s pain levels, range of motion, strength, and functional abilities related to their job tasks. They will then develop a plan to facilitate the employee’s return to work, which may include modifications to their work environment, adaptive equipment, or therapeutic interventions to improve their condition.