Occupational Therapy Evaluation (moderate complexity)

What it is

Occupational therapy is concerned with the ordinary activities a day is made of — dressing, washing, cooking, handling money, using a phone, getting back to a job. The evaluation is the visit where a therapist establishes which of those have become difficult and what is causing the difficulty. It usually combines an interview about how the person actually lives and what changed, a review of the medical history, and hands-on testing: grip and pinch strength, range of motion, coordination, balance, sometimes attention and memory. The output is a written plan — specific goals, the approach that will be used, and how many visits it is expected to take. Evaluation codes come in a graded set, and this one is the middle level; which level applies depends on how much history had to be taken, how many areas of function were affected, and how involved the therapist's judgment had to be. The word "patient/family" in the listing reflects that the history and goals usually come from both.

Why it is done

• To establish a starting point after a stroke, a head injury, or another event that changed what someone can do for themselves
• To plan hand and arm rehabilitation after a fracture, a tendon repair, or other upper-limb surgery
• To work out what is making daily tasks harder in arthritis, Parkinson's disease, multiple sclerosis, and other long-term conditions
• To assess a child whose handwriting, self-care, or coordination is behind what is expected
• To identify equipment, home changes, or different ways of doing a task that would restore independence

What to expect

The evaluation is typically a single appointment of roughly 45 minutes to an hour, longer if standardized tests are used. Comfortable clothing helps, since the therapist will ask for movement. Much of the visit is conversation: what a normal day looks like, what has stopped working, what matters most to get back. Family members are often part of that, especially where memory or safety at home is the concern. Treatment does not always start the same day — sometimes the plan is written first and therapy begins at the next visit. The report goes back to the referring clinician.

Questions worth asking

• Which complexity level was billed, and does the note support it? These levels are priced differently and are assigned by the therapist's judgment.
• If treatment is given on the same day as the evaluation, will there be two charges on one visit?
• Does my plan limit the number of therapy visits per year, and does the evaluation itself count against that limit?
• Is this clinic a hospital outpatient department or an independent practice? The same evaluation often carries a facility fee in the first and not the second.
• Roughly how many follow-up sessions does the plan call for, and what does a treatment session cost compared with this evaluation?