Occupational therapy is a professional field that employs assessment and intervention to develop, recover, and maintain the functions of everyday human activities.
Occupational therapy evaluations typically include an occupational profile, patient medical and therapy histories, relevant assessments, and the development of a plan of care based on the therapist’s clinical reasoning and interpretation of data.
This article explores an integral part of the non-clinical side of occupational therapy: occupational therapy medical billing and coding.
Occupational Therapy Medical Billing & Coding Guide for 2023
Staying up to date on all the latest changes in occupational therapy medical billing and coding is essential for the success of any practice.
Here we present a 101-guide to occupational therapy medical billing/coding.
Certain current procedural terminology (CPT) codes are set by the American Medical Association to designate services provided by occupational therapists. All occupational therapists must have a thorough understanding of the procedure codes needed to run their practice efficiently and bill properly for the services they provide.
We hope that this guide will answer any questions you may have about occupational medical billing and coding wand help your practice avoid claim denials and maximize profits.
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Table of Contents
What Is Included in an Occupational Therapy Evaluation?
- Occupational profile: an individualized evaluation of a patient’s occupational history and experiences, as well as patterns of daily living, interests, values, and needs. This is done between the client/family and the occupational therapist.
- Patient history: the medical and therapy history of the patient.
- Clinical decision making: a customized intervention to improve the patient’s ability to perform daily activities and reach certain goals.
- Development of a plan of care: an outcome evaluation to ensure that goals are being met and/or to modify the intervention plan based on new data.
CPT Codes for Occupational Therapy Evaluation
There are three new codes to describe increasing evaluation complexity: low, moderate, or high. At a minimum, each of the components noted in the code descriptor must be documented, in order to report the selected level of occupational therapy evaluation. For re-evaluation, code 97168 replaces code 97004.
Occupational therapy evaluations include an occupational profile, medical and therapy history, relevant assessments, and development of a plan of care, which reflects the therapist’s clinical reasoning and interpretation of the data.
Coordination, consideration, and collaboration of care with physicians, other qualified health care professionals, or agencies is provided consistent with the nature of the problem(s) and the needs of the patient, family, and/or other caregivers.
At a minimum, each of the components noted in the code descriptor must be documented, in order to report the selected level of occupational therapy evaluation.
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 an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.
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 restrictions; and
Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.
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 restrictions; and
Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.
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.
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Most Common CPT codes for Therapeutic and Modalities Procedures
This is not a comprehensive list of all CPT codes in occupational therapy medical billing. Therapeutic procedures provide a manner of effecting change through the application of clinical skills and/or services that attempt to improve function. Physician or other qualified health care professional (i.e., therapist) required to have direct (one-on-one) patient contact.
The following list contains the most used therapeutic procedures codes and modalities procedure codes that would be rendered by an occupational therapist. Please note the importance of time in certain codes.
Therapeutic Procedures Codes
Therapeutic Procedures Codes
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities 97113 aquatic therapy with therap
aquatic therapy with therapeutic exercises
gait training (includes stair climbing)
massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) (Note: For myofascial release, use 97140)
Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes
add on code 97130
Each additional 15 minutes (List separately in addition to code for primary procedure.)
Unlisted therapeutic procedure (specify)
Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes
Therapeutic procedure(s), group (2 or more) (Report for each member of the group) (Group therapy procedures involve constant attendance by the physician or other qualified health care professional [i.e., therapist], but by definition do not require one-on-one patient contact by the same physician or other health care professional.)
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes
Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes
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Modalities Procedure Codes
A modality is any physical agent applied to produce therapeutic changes to biologic tissue; includes but not limited to thermal, acoustic, light, mechanical, or electric energy.
Supervised The application of a modality that does not require direct (one-on-one) patient contact.
Modalities are used to alleviate pain, improve circulation, reduce swelling, reduce muscle spasm, and deliver medications in conjunction with other procedures.
Application of hot/cold packs to one or more areas
Application of electrical stimulation to one or more areas, unattended by therapist
Application of heat therapy to 1 or more areas
Application of medication through skin using electrical current, 15 minutes each
Application of a modality to one or more areas; vasopneumatic devices
Application of modality to one or more areas; electrical stimulation (manual), 15 minutes each
Iontophoresis, 15 minutes each
Contrast baths, 15 minutes each
Ultrasound, 15 minutes each
Designation of Time
Some occupational therapy medical billing CPT codes are “time-based” codes. Others are “untimed” codes.
All procedures designated by time-based CPT codes are required to follow the Medicare CMS “8-Minute Rule.” The Centers for Medicare & Medicaid Services, or CMS, has released the following statement regarding billing units:
Number of Minutes
8 minutes to < 23 minutes
23 minutes to < 38 minutes
38 minutes to < 53 minutes
53 minutes to < 68 minutes
68 minutes to < 83 minutes
83 minutes to < 98 minutes
98 minutes to < 112 minutes
113 minutes to < 127 minutes
The pattern remains the same for treatment times in excess of 2 hours.
For example, suppose an occupational therapist states that therapeutic exercises were performed on three different areas to develop strength and endurance for 38 minutes. The therapist would report three units for the procedure.
Healthcare professionals should code based on the time units that equate to the appropriate time. The key to occupational therapy medical billing is to understand whether it is a time-based CPT code or an untimed CPT code.
Finally, if there is no time designated in the official descriptor, the code represents a typical session and should only be reported as one unit.
Multiple Procedures with Designation of Time
Since the total time of all procedures is 39 + 23 = 62 minutes, and 62 minutes is reported as 4 units, the total billed units for the session cannot exceed 4.
The procedure performed for the longest amount of time should have the higher number of units. In this example, the provider reduces the units of the shorter procedure (massage exercise) from 2 to 1. This allows the total billable units to not exceed 4.
Hence, the correct way to bill these two procedures is 3 units of the therapeutic exercise and 1 unit of massage exercise.
Occupational Therapy Documentation
This documentation provides a detailed story about the patient, as well as a brief history including review of medical and/or therapy records relating to the presenting problem. All information is derived solely from the patient.
A performance deficit assessment is conducted to pinpoint areas where the patient is unable to finish an activity due to a lack of skill in one of three categories: physical, cognitive, or psychosocial.
An assessment of physical skills seeks to determine whether the patient is impaired in their balance, mobility, strength, endurance, fine or gross motor coordination, sensation, or dexterity.
Deficits noted in the area of cognitive skills refer to the patient’s difficulty attending, perceiving, think, comprehending, problem solve, mentally sequence, and learn or recall information. Documentation may include:
- Range of motion measurements
- Level of independence
- Functional reporting measures
- Psychosocial skills, Cognitive skills
The assessment details the provider’s reasoning and analysis for the entire encounter. It should include a summary of the clinical reasons affecting patient occupational function as well as all information gathered from the subjective and objective sessions.
Some topics to cover include:
- Which therapy options to continue and to terminate.
- Future treatments for the patient.
This is a plan of care for the patient. It comprises short term goals, long terms goals, recommendation(s), and procedure(s) performed or to be performed.
Occupational Therapy Medical Billing and Coding Modifiers
- Modifier GO: services delivered under an outpatient occupational therapy plan of care. Medicare administrative contractors will return or reject claims containing an “always therapy” procedure code and do not also contain the correct discipline-specific therapy modifier.
- Modifier GP: services that are delivered under an outpatient physical therapy plan of care.
- Modifier KX: used to verify that services are medically necessary as justified by the appropriate documentation in the medical record once the threshold amount has been attained. Important! If a claim is submitted with KX modifier and the cap is exceeded, those services will be denied.
- Modifier CO: specifies that services rendered were performed by an occupational therapy assistant under a therapy plan of care.
- Modifier CQ: specifies that services rendered were performed by a physical therapy assistant under a therapy plan of care.
Source: HCPCS Level II – CMS Manual System.
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Most Common Reasons for Occupational Therapy Claim Denials
Audits for Overuse
Providers must make sure to have everything documented for each procedure performed. Some insurance companies will request medical records to review procedures performed during the encounter.
Moreover, insurance companies may examine the overuse of one procedure relative to another to make sure that medical necessity is being met.
It is vital for occupational therapy practice to understand the CMS time-based rule. This is especially true when multiple time-based procedures are performed.
The medical record should keep track of time for each performed procedure and providers must carefully calculate the correct number of units.
Medicare Caps and Payments
Medicare has a usage cap with therapy services. As such, documentation must show that the beneficiary qualities of the therapy services justify a cap exception. Documentation must further show that services are reasonable, necessary, and require the skills of a therapist.
In all cases, failure to follow proper protocols can cause significant loss in revenue for an occupational therapy practice. Be sure to read all occupational therapy medical billing and coding guidelines closely when submitting claims for reimbursement.
This article has covered the essentials of occupational therapy billing and coding.
Proper billing and coding are essential of every occupational therapy practice. Our aim has been to provide helpful insights on properly using occupational therapy CPT codes while also inspiring providers to learn more and explore the topic in more depth.
Would you like some assistance with your medical billing? Neolytix offers a full selection of medical billing services. We’re happy to help with all your occupational therapy medical billing and coding needs.
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