CPT® Code 97165

Official Description

Occupational therapy evaluation, low complexity, requiring these components:

An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem;
An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.

Typically, 30 minutes are spent face-to-face with the patient and/or family.

Common Language Description

Occupational therapy evaluation, low complexity, is a structured assessment process designed to evaluate a patient's ability to perform daily activities and identify any performance deficits that may hinder their independence. This evaluation involves gathering an occupational profile and a comprehensive medical and therapy history, which includes a brief review of relevant medical records related to the presenting problem. The occupational therapist assesses the patient's physical, cognitive, and psychosocial skills to identify 1-3 specific performance deficits that result in limitations in activities or restrictions in participation. The clinical decision-making process during this evaluation is characterized as low complexity, meaning that the analysis of the occupational profile and the data from focused assessments is straightforward, with a limited number of treatment options considered. Importantly, the patient does not present with any comorbidities that would affect their occupational performance, and the evaluation can be completed without the need for modifications or assistance. Typically, this evaluation process involves approximately 30 minutes of face-to-face interaction with the patient and/or their family, ensuring a thorough understanding of the patient's needs and capabilities.