OT Medicare Part B

Evaluation Checklist
& Quality Measures
This checklist is not comprehensive and does not replace the clinical judgement of an occupational therapist. The checklist should
be used as a reminder of baseline areas that should be addressed during the OT evaluation process. The areas below relate to
occupation-based practice and quality performance measures.

A comprehensive occupational therapy evaluation is based on a theoretical model and follows the occupational therapy practice
framework. A top-down approach identifies occupations that are challenging and important to the client and then assesses
related performance skills, client factors, environments and context, and performance patterns.

For more information on the Quality Payment Program Merit-Based Incentive Payment System (MIPS), this checklist, and
occupational therapy click on “Quality Payment Program” at www.aota.org/value.

Occupational Profile:
Download the template at www.aota.org/profile.
† Reason for OT services
† Successful occupations
† Interests & Values
† Occupational History
Performance Patterns
† Habits  Routines  Roles  Rituals
† Environment: Supports & Barriers (Physical, Social)
† Context: Supports & Barriers (Cultural, Personal, Temporal, Virtual)

Analysis of Occupational Performance

Click on the Quality Toolkit at www.aota.org/value for links to standardized assessments and screeners used in each of the
areas below.

Addressed Is this area a Priority Addressed Is this area a Priority

Occupations
ADLs   IADLs  
Performance Skills
Psychosocial/Behavior Fall Prevention/Fear of
   
Skills Falling
Client Factors
In addition to areas identified while addressing ADLs and IADLs (e.g., motor, sensation, pain)
Vision   Functional Cognition  
Performance Patterns
Habits, Routines, Roles  
Contexts & Environments
Include Safety Screen  
QPP MIPS Quality Measures (2021)
Download details of the measures including collection type at www.aota.org/value.

Measures Finalized for PHYSICAL THERAPY / OCCUPATIONAL THERAPY Specialty List

Done High Priority Quality # Measure Title and Description
128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
 G8422: BMI not Documented, Patient Not Eligible
 G8938: BMI Documented Outside of Normal Limits, Follow-up Plan not Documented, Patient Not Eligible
 G8420: BMI Documented as Normal, No Follow-Up Plan Required, Performance Met
 G8417: BMI Documented as Above Normal Parameters, AND Follow-Up Documented, Performance Met
 G8418: BMI Documented as Below Normal Parameters, AND Follow-Up Documented, Performance Met
 G9716: BMI Documented Outside of Normal Limits, Follow-Up Plan not Completed for Documented Reason, Denominator
Exception
 G8421: BMI not Documented, Reason not Given , Performance Not Met
 G8419: BMI Documented Outside of Normal Parameters, Follow-Up Plan not Documented, Reason not Given, Performance
Not Met
! 130 Documentation of Current Medications in the Medical Record
 G8427: Current Medications Documented, Performance Met
 G8430: Current Medications not Documented, Patient not Eligible, Denominator Exception
 G8428: Current Medications with Name, Dosage, Frequency, or Route not Documented, Reason not Given, Performance
Not Met
! 182 Functional Outcome Assessment
 G8539: Functional Outcome Assessment Documented as Positive AND Care Plan Documented, Performance Met
 G8942: Functional Outcome Assessment Documented AND Care Plan Documented, if Indicated, Within the Previous
30 Days, Performance Met
 G8542: Functional Outcome Assessment Documented, No Functional Deficiencies Identified, Care Plan not Required,
Performance Met
 G9227: Functional Outcome Assessment Documented, Care Plan not Documented, Patient not Eligible, Denominator
Exception
 G8540: Functional Outcome Assessment not Documented, Patient not Eligible, Denominator Exception
 G8541: Functional Outcome Assessment not Documented, Reason not Given, Performance Not Met
 G8543: Functional Outcome Assessment Documented as Positive, Care Plan not Documented, Reason not Given,
Performance Not Met
! 154 Falls: Risk Assessment
 G9718: Patient receiving Hospice Services, Patient Not Eligible
 1101F: Not at Risk for Falls (documentation of no falls or only one fall without injury), Denominator Exclusion
 1101F-8P: Fall status is not documented, Denominator Exclusion
 3288F & 1100F: Risk Assessment for Falls Completed AND Patient screened for future fall risk, Performance Met
 3288F-1P & 1100F: Risk Assessment for Falls not Completed for Medical Reasons, Denominator Exception
 3288F-8P & 1100F: Risk Assessment for Falls not Completed, Reason not Otherwise Specified, Performance Not Met
! 155 Falls: Plan of Care
 G9720: Patient receiving Hospice Services, Patient Not Eligible, Denominator Exclusion
 CPT II 0518F: Plan of Care Documented, Performance Met
 0518F with 1P: Risk Assessment for Falls not Completed for Medical Reasons, Denominator Exception
 0518F with 8P: Plan of Care not Documented, Reason not Otherwise Specified, Performance Not Met
134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
 G9717: Depression Screening or Follow-Up Plan not Documented, Patient not Eligible, Denominator Exclusion
 G8431: Screening for Depression Documented as Positive, AND Follow-Up Plan Documented, Performance Met
 G8510: Screening for Depression Documented as Negative, Follow-Up Plan not Required, Performance Met
 G8433: Screening for Depression not Completed, Documented Reason, Denominator Exception
 G8432: Screening for Depression not Documented, Reason not Given, Performance Not Met
 G8511: Screening for Depression Documented as Positive, Follow-Up Plan not Documented, Reason not Given,
Performance Not Met
! 181 Elder Maltreatment Screen and Follow-Up Plan
 Done High Priority Quality # Measure Title and Description
 G8733: Elder Maltreatment Screen Documented as Positive AND Follow-Up Plan Documented, Performance Met
 G8734: Elder Maltreatment Screen Documented as Negative, Follow-Up Plan not Required, Performance Met
 G8535: Elder Maltreatment Screen not Documented, Patient not Eligible, Denominator Exception
 G8941: Elder Maltreatment Screen Documented as Positive, Follow-Up Plan not Documented, Patient not Eligible for
Follow-Up Plan, Denominator Exception
 G8536: Elder Maltreatment Screen not Documented, Reason not Given, Performance Not Met
 G8735: Elder Maltreatment Screen Documented as Positive, Follow-Up Plan not Documented, Reason not Given,
Performance Not Met

226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
 G9902: Patient Screened for Tobacco Use, Identified as a Tobacco User or Tobacco Non-User, Performance Met
 G9903: Patient Screened for Tobacco Use AND Identified as a Tobacco Non-User, Performance Met
 G9904: Tobacco Use Screening not Performed for Medical Reasons, Denominator Exception
 G9905: Tobacco Use Screening not Performed, Reason Not Given, Performance Not Met

Measures Below Cannot be Submitted via Claims

Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy—
126
Neurological Evaluation
Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention—Evaluation of
127
Footwear
! 217 Functional Status Change for Patients with Knee Impairments FOTO (Outcome)
! 218 Functional Status Change for Patients with Hip Impairments FOTO (Outcome)
Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments
! 219
FOTO (Outcome)
Functional Status Change for Patients with Low Back Impairments FOTO
! 220
(Outcome)
Functional Status Change for Patients with Shoulder Impairments FOTO
! 221
(Outcome)
Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
! 222
FOTO (Outcome)
281 Dementia: Cognitive Assessment
! 288 Dementia: Education and Support of Caregivers for Patients with Dementia
! 318 Falls: Screening for Future Fall Risk
! 478 Functional Status Change for Patients with Neck Impairments
Additional Measures Reportable by OT Below Cannot be Submitted via Claims
Dementia: Associated Behavioral and Psychiatric Symptoms Screening and
283
Management
286 Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia

Lookup details for individual measures by visiting https://qpp.cms.gov/mips/explore-measures.

www.aota.org