Code Crunchers
This code is used for an integrated biopsychosocial assessment or an initial evaluation
What is 90791?
One of the two assessments conducted during intake to gather information about the client's functioning
What is the WHODAS or the DSM-5-TR Cross-Cutting Measure?
Notes must be locked/signed within this time frame
What is 24-48 hours?
This acronym stands for the federal agency that oversees Medicare and Medicaid programs
What is CMS (Centers for Medicare & Medicaid Services)?
This is the term for specific, measurable, achievable, relevant, and time-bound goals that guide occupational therapy interventions.
What are SMART goals?
This code is used for 53min+ of psychotherapy
What is 90837?
This inquiry is made to uncover a client's typical activities and routines
What is a typical day for you? OR How would you describe your daily routine?
Diagnoses from this text are used for Medicaid clients
What is the DSM?
In documentation, this term refers to information that is based on what you directly observe or measure
What is objective data?
This type of goal in occupational therapy focuses on improving a client's ability to perform specific activities of daily living, such as dressing or cooking.
What are functional goals?
This code is used for a low complexity OT evaluation and is intended to last this long
What is 97165 for 30 minutes?
This systematic process involves using specific criteria to evaluate a client's functional capabilities, yielding measurable results
What is an objective screening?
If completing a home visit, you would generally want to park here
What is in a visitor/public parking spot?
These are the three key components that documentation should generally include to demonstrate the medical necessity of services provided
What are description of the patient's condition, treatment provided, and treatment outcomes?
The collaborative process of reviewing and modifying goals with clients, considering their evolving needs and progress, is known as goal __________.
What is "reassessment" or "review"?
These are generally the first two numbers of medical codes used in occupational therapy
What are “97”?
In occupational therapy, this term describes a person's engagement in meaningful activities that bring them joy and satisfaction
What is occupation-based activity?
This federal law enacted in 1996 ensures the privacy and security of patient information
What is the Health Insurance Portability and Accountability Act (HIPAA)?
This type of documentation is a legal record that can be admitted as evidence in a court of law
What is legal documentation?
Client-centered goals in occupational therapy are often framed around achieving improved independence, enhanced quality of life, and increased __________ participation.
What is "community" or "societal" participation?
These are generally the first two numbers of behavioral health codes for Medicaid
What are “90”?
This influential occupational therapy framework emphasizes the interplay between a person's volition, habituation, performance capacity, and the environment in shaping their engagement in meaningful activities
What is the Model of Human Occupation (MOHO)?
This term refers to the process of periodically reviewing and updating documentation to ensure accuracy and compliance
What is documentation audit?
This term refers to the process of ensuring that documentation reflects the actual services provided and is consistent with the billing claims submitted
What is documentation accuracy?
When creating client-centered goals, occupational therapists collaborate with clients to identify their strengths, limitations, and aspirations, focusing on their unique __________.
What is "occupational profile"?