CPT Coding for Occupational Therapy

Sep 22, 2020 8:47:45 PM

Using the wrong occupational therapy CPT code is a simple mistake to make — but it can have significant consequences. Inaccurate coding can result in over- or under-billing, and it can cause your claim to be denied. While there are a host of benefits to accurate coding, there are just as many common barriers. Let’s look at each and how you can reduce your rejections and denials with correct coding.  We’ll close with an extensive list of the most commonly used CPT codes for evaluations, therapeutic procedures, and modalities. 

Why Accurate Occupational Therapy CPT Codes Matter

It’s always easier to do things right the first time. This certainly holds true when billing for occupational therapy services. Here are four valuable benefits of accurate coding. 

  • Faster reimbursement process — Using correct CPT codes cuts down on the wait time to be paid for your services. Fast reimbursement will help maintain your cash flow. Check out 3 Options for Managing Your Therapy Clinic's Revenue Cycle to learn more about how to improve your cash flow. 
  • Reduced claims rejections — Using the right code the first time decreases the chances that the claim will be rejected. Resubmitting claims can be a time-consuming and frustrating process, especially when you’d rather be spending that time treating clients.
  • Improved profitability — Using the correct code will ensure receive all the reimbursement that you’re due for a service you provided. Accurate coding is especially important when it comes to coding for timed procedures. Under-coding means you’re providing some of your services for free. 
  • Audit protection — Overusing the same CPT codes or making frequent coding mistakes can send up a red flag, increasing the chances of an audit. 

Barriers to Accurate CPT Coding

It’s easy to make mistakes with occupational therapy coding because there’s only one way to do it right but many ways to get it wrong. Here are a few of the most common CPT coding mistakes.

  • Not using a current code — CPT codes are updated regularly. Keeping current on he latest list can be a challenge.
  • Using a similar but not fully-accurate code — Some CPT codes are very similar. Choosing the best one to describe the service you provided is sometimes a judgment call. Err on the conservative side, but make sure you bill for all of the services you provided.
  • Using an incorrect combined services code — Procedures commonly performed together are frequently bundled into a single CPT code. Selecting the right bundled service code is critical to reducing claims rejections. 
  • Failing to use timed codes accurately — Many occupational therapy codes are timed codes. One unit of a timed code is considered to be 15 minutes spent. Due to Medicare’s 8-Minute Rule (which has become standard for private insurers), it can be confusing to calculate your billable time. Use this guide to help.
  • Incorrectly used or missing modifiers — Modifiers provide supplemental information about a procedure or offer additional details about the services. One example is the infamous Modifier 59. This is the modifier used to bill separately for two services that are typically considered inclusive. The incorrect use of modifier codes can invite unwanted scrutiny from insurers.

Occupational Therapy CPT Codes

Below is a current list of CPT codes for the most common occupational therapy services. We’ve grouped the codes into three categories for easier navigation: occupational therapy evaluations, therapeutic procedures, and modalities.

Evaluation Codes

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 that identifies 1–3 performance deficits (i.e., 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 (e.g., physical or verbal] with assessment is not necessary to enable completion of 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 that identifies 3–5 performance deficits (i.e., 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, 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 is necessary to enable patient to complete evaluation component.
  • Typically, 45 minutes are spent face to face with the patient and/or family.

97167 — 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 review of physical, cognitive, or psychosocial history related to current functional performance;
  • An assessment that identifies 5 or more performance deficits (i.e., 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, 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 is necessary to enable patient to complete evaluation component.
  • Typically, 60 minutes are spent face to face with the patient and/or family.

97168 — 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.
  • Typically, 30 minutes are spent face to face with the patient and/or family.

Therapeutic Procedure Codes 

  • 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
  • 97124 — Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
  • 97129 — Therapeutic interventions that focus on cognitive function (eg, 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
  • 97130 — 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; each additional 15 minutes (List separately in addition to code for primary procedure)
  • 97139 — Unlisted therapeutic procedure (specify)
  • 97140 — Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
  • 97150 — Therapeutic procedure(s), group (two or more individuals)
  • 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
  • 97535 — Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes
  • 97542 — Wheelchair management (eg, assessment, fitting, training), each 15 minutes
  • 97597 — Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high-pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters
  • 97598 — Total wound(s) surface area greater than 20 square centimeters
  • 97760 — Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes
  • 97761 — Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes
  • 97763 — Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes

Modality Codes

  • 90901 — Biofeedback training by any modality
  • 97016 — Application of modality to one or more areas; vasopneumatic devices
  • 97018 — Paraffin bath
  • 97022 — Whirlpool
  • 97032 -—Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
  • 97033 – Iontophoresis, each 15 minutes
  • 97034 — Contrast baths, each 15 minutes
  • 97035 — Ultrasound, each 15 minutes

Using the Right OT CPT Code is Worth the Effort

If you’re new to billing, CPT coding can be overwhelming. But accurate CPT coding is essential for a healthy occupational therapy practice. Using the right codes ensures you receive timely reimbursement for your services and reduces your chances of an audit. You'll also spend less time resubmitting claims rejections and more time working with clients. 

Fusion Web Clinic helps making billing easier. You can see a list of current codes and auto-create claims to speed the process. Try a demo today!

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