Occupational Therapy Evaluation (high complexity)

What it is

Occupational therapy is named for occupation in the old sense — what fills a person's day. The evaluation is an assessment of ordinary tasks: washing, dressing, eating, preparing food, managing medication, handling stairs and doorways, driving, working, caring for children. The therapist takes a history of how the person managed before, tests the physical side of it — strength, grip, range of movement, balance, coordination, sensation — and looks at the thinking side too, since memory, attention, and planning decide whether someone can follow a recipe or manage their own tablets.

Occupational therapy evaluations are coded at three levels of complexity, and this is the highest one. The level reflects how tangled the assessment is: how many areas of function are affected, how much history and how many contributing conditions have to be accounted for, and how much clinical reasoning goes into building the plan. It is not a statement about how severe the illness is or how long the appointment ran. The family or caregiver is usually part of the session, because they are the ones who will see what happens at home.

Why it is done

• To establish what a person can and cannot do independently, in concrete everyday terms rather than in test scores
• To separate the reasons — weakness, stiffness, pain, poor balance, reduced sensation, memory and planning difficulties — because each leads somewhere different
• To identify equipment, home modifications, or different ways of doing a task that would restore independence
• To set measurable goals and a plan of care that the therapy sessions afterward work toward
• To assess someone after a stroke, a brain or spinal injury, a hand injury, a joint replacement, or with a condition that is progressing

What to expect

The appointment is long compared with a therapy session and is mostly conversation and demonstration: describing a normal day, then showing how a task is actually done. Expect questions about the layout of the home — steps, bathroom, where things are kept — and about what help is available. Physical measurements are taken with simple instruments. Nothing hurts beyond the effort of the tasks themselves. The result is a written plan with goals, which the therapist goes over, and treatment sessions start from there, usually at a later visit.

Questions worth asking

• Which complexity level was billed? Low, moderate, and high OT evaluations are three separate codes at three prices, and the level is the therapist's judgement, not a fixed property of the diagnosis.
• If a treatment session is delivered on the same day as this evaluation, does a second charge appear for that day?
• Re-evaluation later in a course of therapy is its own code. Is one planned, and what does it cost?
• If equipment is recommended, is it supplied and billed by this practice or bought separately, and is the fitting visit a further charge?
• Is this being done in a hospital outpatient department, where a facility fee is typically added, or in a freestanding therapy practice?