Universal Clinical Codes & Terminology Search

Therapeutic interventions that focus on cognitive function (eg attention memory reasoning executive function problem solving and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg managing time or schedules initiating organizing and sequencing tasks) direct (one-on-one) patient contact; each additional 15 minutes (list separately in addition to code for primary procedure)

Unlisted therapeutic procedure (specify)

Manual therapy techniques (eg mobilization/ manipulation manual lymphatic drainage manual traction) 1 or more regions each 15 minutes

Therapeutic procedure(s) group (2 or more individuals)

Behavior identification assessment administered by a physician or other qualified health care professional each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations and non-face-to-face analyzing past data scoring/interpreting the assessment and preparing the report/treatment plan

Behavior identification-supporting assessment administered by one technician under the direction of a physician or other qualified health care professional face-to-face with the patient each 15 minute

Adaptive behavior treatment by protocol administered by technician under the direction of a physician or other qualified health care professional face-to-face with one patient each 15 minute

Group adaptive behavior treatment by protocol administered by technician under the direction of a physician or other qualified health care professional face-to-face with two or more patients each 15 minutes

Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional which may include simultaneous direction of technician face-to-face with one patient each 15 minutes

Family adaptive behavior treatment guidance administered by physician or other qualified health care professional (with or without the patient present) face-to-face with guardian(s)/caregiver(s) each 15 minutes

Multiple-family group adaptive behavior treatment guidance administered by physician or other qualified health care professional (without the patient present) face-to-face with multiple sets of guardians/caregivers each 15 minutes

Group adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional face-to-face with multiple patients each 15 minutes

Physical therapy evaluation: low complexity requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions activity limitations and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standar

Physical therapy evaluation: moderate complexity requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions activity limitations and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision maki

Physical therapy evaluation: high complexity requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions activity limitations and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decisi

Re-evaluation of physical therapy established plan of care requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically 20 minutes are spent face-to-face with the patient and/or family.

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 a

Occupational therapy evaluation moderate complexity requiring these components: An occupational profile and medical and therapy history which includes an expanded review of medical and/or therapy records and additional review of physical cognitive or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie relating to physical cognitive or psychosocial skills) that result in activity limitations and/or participation restriction

Occupational therapy evaluation high complexity requiring these components: An occupational profile and medical and therapy history which includes review of medical and/or therapy records and extensive additional review of physical cognitive or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie relating to physical cognitive or psychosocial skills) that result in activity limitations and/or participation restriction

Re-evaluation of occupational therapy established plan of care requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Ty