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
What Is Included in an Occupational Therapy Evaluation?
A typical occupational therapy evaluation includes the following components:
- Occupational profile
The history of the patient’s involving his 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.
We can help.
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:
Typically, 30 minutes are spent face-to-face with the patient and/or family |
|
97166 |
Occupational therapy evaluation, moderate complexity, requiring these components:
Typically, 45 minutes are spent face-to-face with the patient and/or family |
|
96167 |
Occupational therapy evaluation, high complexity, requiring these components:
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:
Typically, 30 minutes are spent face-to-face with the patient and/or family |
- No long-term commitment
- Hourly billing services available
- Improvement Guaranteed
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 |
Ask us for Help!
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 |
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.
Multiple Procedures with Designation of Time
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.
When an occupational therapist performs multiple procedures during the same encounter, the units to be reported are based on the 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.
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.
We can help.
Most Common Reasons for Occupational Therapy
Claim Denials
- Incorrect Modifiers
- Audits for Overuse
- Incorrect calculation of Time-Based Codes
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.
