Mr. L is completing UB dressing tasks while seated at the ed…

Mr. L is completing UB dressing tasks while seated at the edge of the bed. He is able to thread both arms through his shirt and pull the shirt over his head. Therefore, he completes 3/3 UB dressing tasks. He requires occasional steadying to maintain his seated balance. How would you score the UB dressing GG code using the following scale?  Coding: Safety and Quality of Performance – If helper assistance is required because patient’s/resident’s performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices. 06. Independent – Patient/resident safely completes the activity by him/herself with no assistance from a helper. 05. Setup or clean-up assistance – Helper sets up or cleans up; patient/resident completes activity. Helper assists only prior to or following the activity. 04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient/resident completes activity. Assistance may be provided throughout the activity or intermittently. 03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01. Dependent – Helper does ALL of the effort. Patient/resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient/resident to complete the activity.

You receive an OT order to evaluate and treat. During your e…

You receive an OT order to evaluate and treat. During your evaluation, you determine your chart review time was brief due to minimal (2) co-morbidities.  During your evaluation you determined there were 2 performance factors limiting occupational performance. The time you spent with your client was under 30 minutes. What evaluation code would you bill?