You performed a top-down evaluation in the acute care settin…
You performed a top-down evaluation in the acute care setting. You identified through the chart review that the patient is admitted following spinal surgery, their pain is being managed with pain medication, and they have activity precautions. The physician requested an OT evaluation to assess ADL participation and safety for homegoing. You spent 30 minutes in the patient’s room for your initial bedside evaluation. Overall, the chart review process was extensive due to the patient’s social history, your assessment revealed 4 performance deficits, and your detailed assessment revealed that there are multiple treatment options available. Minimal to moderate task modifications will be necessary for the patient to safely perform ADLs after discharge. What evaluation CPT code would you bill for this patient?
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