Occupational Therapy Medical Billing & Coding Guide for 2024

Occupational Therapy Medical Billing & Coding Guide for 2021

Occupational therapy is a professional field that employs assessment and intervention to develop, recover, and maintain the functions of everyday human activities. An occupational therapist assists people with physical, sensory, or cognitive disabilities to regain the required strength.  

This article explores an integral part of the non-clinical side of occupational therapy, which is Occupational Therapy Medical Billing and Coding.

Table of Contents

Occupational Therapy Medical Billing & Coding Guide for 2021

What Is Included in an Occupational Therapy Evaluation?

A typical occupational therapy evaluation includes the following components:  

  • Occupational profile 

The history of the patient involving their occupational history is one of the major components that is considered during the Occupational therapy evaluation. Also, his interests, values, needs and patterns of daily living are taken into consideration to a great extent.

  • Patient history 

The medical and therapeutic history of the patient is also a significant component for the evaluation of occupational therapy.

  • 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 

This component of the occupational therapy evaluation involves formulating a customized plan for the care of the patient and ensuring that the goals are met accurately.

 The level of occupational therapy evaluation performed is determined by the patient’s condition, complexity of clinical decision, and the scope and nature of the patient’s performance deficits relating to physical, cognitive, or psychosocial skills to be assessed.

The patient’s therapeutic plan is constructed in a way that reflects each of the performance deficits, including-  

a. Physical skills: Refers to the impairment of body structure or body function.  

b. Cognitive skills: Refers to ability to attend, perceive, think, understand, problem solve, mental sequence and remember resulting in the ability to organize occupational tasks.

c. Psychosocial skills: Refers to interpersonal interactions, habits, routines and behaviors which are required to actively participate in daily activities.  

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CPT Codes for Occupational Therapy Evaluation

There are three 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.  

Sources: AOTA; AOTA New Occupational Therapy Evaluation Coding Overview.

CPT Code Description

97165

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 the evaluation component.

Typically, 30 minutes are spent face-to-face with the patient and/or family

97166

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 the patient to complete the evaluation component.

Typically, 45 minutes are spent face-to-face with the patient and/or family

96167

Occupational therapy evaluation, high complexity, requiring these components:

  • An occupational profile and medical and therapy history, which includes a 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 the patient to complete the evaluation component.

Typically, 60 minutes are spent face-to-face with the patient and/or family

96168

Re-evaluation of occupational therapy established plan of care, requiring these components:

  • An assessment of changes in patient functional or medical status with a 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.

Typically, 30 minutes are spent face-to-face with the patient and/or family

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Most Common CPT codes for Therapeutic and Modalities Procedures

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
CPT Code
Description

97110

Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

97112

Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

97113

Aquatic therapy with therapeutic exercises

97116

Gait training (includes stair climbing)

97124

Massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) (Note: For myofascial release, use 97140)

97129

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.)

97139

Unlisted therapeutic procedure (specify)

97140

Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

97150

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.)

97530

Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes

97533

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.

CPT Code
Description

97010

Application of hot/cold packs to one or more areas

97014

Application of electrical stimulation to one or more areas, unattended by therapist

97024

Application of heat therapy to 1 or more areas

97033

Application of medication through skin using electrical current, 15 minutes each

97016

Application of a modality to one or more areas; vasopneumatic devices

97018

Paraffin bath

97022

Whirlpool

97032

Application of modality to one or more areas; electrical stimulation (manual), 15 minutes each

97033

Iontophoresis, 15 minutes each

97034

Contrast baths, 15 minutes each

97035

Ultrasound, 15 minutes each

Man in wheelchair talking with psychotherapist

CMS 8 Minutes Rule

Ever heard about CMS 8-Minute rule? A recent statement has been released by CMS which states the following

When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes. For any single timed CPT code in the same day measured in 15-minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes. If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes through and including 37 minutes, then 2 units should be billed.

Source: CMS Manual System. The following chart outlines the time units to be reported based on the times specified in the medical documentation. For all CPT codes designated as 15 minutes, multiple coding represents the minimum face-to-face treatment for the specific CPT code reported:  

Units
Number of Minutes

1 unit

8 minutes to < 23 minutes

2 units

23 minutes to < 38 minutes

3 units

38 minutes to < 53 minutes

4 units

53 minutes to < 68 minutes

5 units

68 minutes to < 83 minutes

6 units

83 minutes to < 98 minutes

7 units

98 minutes to < 112 minutes

8 units

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.

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Multiple Procedures with Designation of Time

When an occupational therapist performs multiple procedures during the same encounter, the units to be reported are based on the sum total time of all the procedures. Suppose, during one session, a provider performed 39 minutes of therapeutic exercise (normally 3 units) and 23 minutes of massage exercise (normally 2 units). In this case, it would be incorrect to bill 3 units of therapeutic exercise and 2 units of massage exercise for this session. This is due to the following CMS rule:

If more than one 15-minute timed CPT code is billed during a single calendar day, then the total number of timed units that can be billed is constrained by the total treatment minutes for that day.

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.  

Mature clinician in uniform helping young man in pain to sit in wheelchair

Occupational Therapy Documentation

There are four components that must be present in each medical record. This format, sometimes known as SOAP, is the standard occupational therapy documentation format. To have a perfect SOAP format, here are a few things that a therapist must keep in mind:

S = Subjective

What is the client reporting?  
What are the client’s parents or caregivers reporting?  
Is the client reporting pain?  
Are they complaining of fatigue?

O = Objective

What level of assistance did the client need?  
How many verbal and physical prompts were provided?  
What did you observe?  
How did you grade the activity or modify the environment?  
In what percentage of trials was the client successful?  
What progress is the client currently making on their goals?

A = Assessment

After examining the subjective and objective data, what does this mean about your client’s progress?  
Why did you select a certain intervention activity?  
Have there been any significant changes in functioning?

P = Plan

Should the treatment plan be changed? How?  
Does a new referral need to be made?  
Are any accommodations or modifications recommended?

Occupational Therapy Medical Billing and Coding Modifiers

Modifiers indicate that a performed service or procedure has been altered by some circumstance but not changed in its definition or occupational therapy medical billing code. To receive proper payments for services rendered, the following modifiers are used when reporting occupational therapy procedures:  

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

  • Incorrect Modifiers
  • Audits for Overuse
  • Incorrect calculation of Time-Based Codes
Boy exercising with therapist

Conclusion

Proper billing and coding practices are essential for every occupational therapy practice. At Neolytix, we aim to provide helpful insights on properly using occupational therapy CPT codes to ensure they do their best to optimize their billing processes to maximize reimbursements.

Neolytix has been helping occupational therapist organizations nationwide improve their financial health for almost 12 years. Schedule a demo with us and let us show you how our coding audit service, medical billing and coding services or comprehensive revenue cycle management services can benefit your organization. 

FAQs: Demystifying Occupational Therapy Billing and Coding

Understanding Occupational Therapy Billing and Coding

Modifiers in medical billing and coding indicate that a performed service or procedure has been altered by some circumstance but not changed in its definition or CPT code. Common modifiers include GO, GP, KX, CO, and CQ, which help in accurately reporting services for proper reimbursement, thereby reducing OT billing errors. 

 

CPT Code 97110 is used for therapeutic exercises aimed at developing strength, endurance, range of motion, and flexibility. These exercises are performed in 15-minute increments and are critical in occupational therapy billing. 

CPT Code 97110 (therapeutic exercises) and 97140 (manual therapy techniques) can be billed together if they are distinct services provided in the same session. However, it's essential to use the appropriate modifier to prevent billing errors OT. 

Yes, CPT Code 97110 often requires a modifier to indicate the specific circumstances of the service provided. For instance, modifiers like GO or KX may be necessary to ensure proper billing and avoid OT billing mistakes. 

CPT Code 97110 refers to therapeutic exercises performed to improve a patient's physical functions. These exercises are essential in both occupational and physical therapy for enhancing strength, flexibility, and range of motion. 

The 97110 CPT Code is used to document and bill for therapeutic exercises that a therapist performs with a patient, typically in 15-minute intervals, to improve physical abilities. 

CPT Code 97110 is used in occupational therapy billing for therapeutic exercises aimed at developing and improving a patient's physical capabilities such as strength and flexibility. Proper use of this code helps in minimizing coding errors OT. 

CPT Code 97530 is used for therapeutic activities involving the use of dynamic activities to improve functional performance, billed in 15-minute increments. It is crucial in both occupational and physical therapy settings. 

CPT Code 97530 is used in both occupational therapy and physical therapy. It covers therapeutic activities designed to improve a patient's functional performance, making it versatile across disciplines. 

CPT Code 97165 represents an occupational therapy evaluation of low complexity. This code includes assessing the patient's condition and developing a treatment plan based on the evaluation, essential for OT billing guide accuracy. 

The 97165 CPT Code is for a low-complexity occupational therapy evaluation. It involves a comprehensive review of the patient's history and a limited number of performance deficits, fundamental in OT evaluation codes. 

CPT Code 97165 was introduced as part of the 2017 updates to the CPT coding system. It is used to classify low-complexity occupational therapy evaluations and improve the accuracy of OT ICD-10 reporting. 

No, a physical therapist generally cannot bill for occupational therapy services unless they hold the necessary credentials and licensure in both disciplines. This ensures compliance and avoids OT billing mistakes, coding errors ICD-10, and other ICD-10 mistakes. Accurate billing practices are crucial to avoid OT billing mistakes and ensure compliance. Ensuring the correct use of CPT codes, such as OT 97165, CPT Code 97110 vs 97530, and medium complexity CPT codes, helps maintain accuracy and compliance. Understanding the top ICD-10 codes relevant to both fields is essential for proper billing and coding practices. 

The new OT evaluation codes, introduced in 2017, include CPT Codes 97165, 97166, and 97167. These codes categorize evaluations based on complexity—low, medium, and high, respectively, enhancing the precision of OT billing. 

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