Occupational Therapy CPT Code Level Verification of Benefits

The most common CPT codes for occupational therapy are:

• 97165: Occupational therapy evaluation, low complexity
• 97166: Occupational therapy evaluation, moderate complexity
• 97167: Occupational therapy evaluation, high complexity
• 97168: Occupational therapy re-evaluation

CPT code level benefits are important to check before seeing a patient. Unfortunately these benefits are not readily available online and necessitate a phone call to the payer to tell you if these CPT codes are covered.

When calling a payer, you should be asking the following questions for each CPT code above. This may seem tedious but it is necessary. When you finally get in touch with a live rep, the first thing you want to do is say that you are checking occupational therapy benefits and that you have specific codes you’d like to check.

Provide one CPT code at a time to the representative and get the full benefits and limitations for that CPT code.

Make sure they are answering the following questions:

• Is there a copay? Is there a coinsurance?
• Is authorization required and if yes, when and how do you submit the authorization request?
• Do these procedure codes count towards the patient’s deductible?
• Are there any limitations on coverage for these CPT codes, such as a max number of visits/hours/units?
• If yes to above, how many visits/hours/units have been accumulated thus far?
• Is a referral required? If yes, when and how do you submit the referral.