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Navigating CPT Codes in Occupational Therapy

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Current Procedural Terminology (CPT) codes, developed by the American Medical Association (AMA), are almost a secret language of healthcare billing. They provide a standardized framework for documenting and billing healthcare services. Even experienced providers can struggle to choose the right code, so we wrote this blog post to demystify CPT codes for occupational therapists. We’ll clarify how to apply them and how coding can impact your practice.

 

Timed vs. Untimed CPT Codes

Codes for occupational therapy are split into two main categories – timed and untimed codes. Untimed codes come with a flat fee, no matter how long it takes, and are charged once per treatment session. Each untimed code counts as one billable unit.

On the flip side, timed codes are based on the amount of skilled intervention time given to the patient. When submitting timed codes, it’s important to calculate the right number of units for the payer.

 

Determining Billable Units

Determining the total units will vary based on whether the payer follows the Center for Medicare and Medicaid Services (CMS) 8-Minute Rule or the American Medical Association’s (AMA) ‘Rule of Eights or >50%’.

The CMS 8-Minute Rule involves assigning time increments in 15-minute intervals, starting from at least 8 minutes. The total minutes of timed procedures and modalities for the entire session determines the number of billable units. Conversely, AMA’s guidelines determine units based on the total time spent on specific CPT codes, irrespective of the overall treatment duration.

Under the CMS 8-Minute Rule, time is divided into 15-minute intervals, starting from a minimum of 8 minutes. Initially, sum up the minutes for all timed procedures and modalities provided during the session. This total duration of timed code treatment minutes dictates the number of units billed. Once the total minutes are calculated, refer to the chart below for the total units.

  • 1 unit: > 8 to 22 minutes
  • 2 units: > 23 to 37 minutes
  • 3 units: > 38 to 52 minutes
  • 4 units: > 53 to 67 minutes
  • 5 units: > 68 to 82 minutes
  • 6 units: > 83 to 97 minutes
  • 7 units: > 98 to 112 minutes
  • 8 units: > 113 to 127 minutes

 

However, according to the AMA, a unit is achieved when the midpoint is surpassed. This approach tallies minutes based on the CPT codes billed versus the total treatment time. For instance, if a provider bills 8 minutes of 97112, 8 minutes of 97535, and 8 minutes of 97350, the Total Time equals 24 minutes. This translates to 3 units for payers following AMA guidelines but only 2 units for those adhering to CMS guidelines.

 

CPT Codes Used in Occupational Therapy

Occupational therapy providers use a variety of CPT codes to document the services they provide to patients. These can be broken down into a few categories.

 

Evaluation and Assessment Codes

These codes are used to document the initial assessment of a patient’s functional abilities or a reassessment due to a significant change in status. These codes are all untimed.

Examples include:

  • 97165: Occupational therapy evaluation, low complexity
  • 97166: Occupational therapy evaluation, moderate complexity
  • 97167: Occupational therapy evaluation, high complexity
  • 97168: Re-evaluation: used when there is a documented change in functional status or a significant change to the plan of care is required.

 

The complexity of the evaluation is based on the medical history related to the presenting problem, the number of performance deficits resulting in activity limitations, and the clinical decision-making required to complete the evaluation.

 

Therapeutic Intervention Codes

These codes represent the various interventions provided during occupational therapy sessions. These codes require the direct skill of an occupational therapist and must be documented as such. When choosing therapeutic intervention codes, consider the specific purpose behind the intervention to select the most appropriate CPT code.

For example, the intervention of working with a patient and having them tap a balloon back and forth could be billed in a variety of ways depending on the intent. If the purpose is to address bilateral upper extremity coordination, it’s neuromuscular re-education. If it’s to improve UE ROM, strength, and endurance, it’s therapeutic exercises, and if it’s to promote dynamic reaching, it’s therapeutic activities.

Examples of commonly used CPT codes include:

  • 97350: Therapeutic Activities – Use of dynamic activities to improve functional performance. Examples of such activities include lifting, pushing, pulling, reaching, throwing, functional mobility, and transfer training.
  • 97535: Self Care/Home Management Training – Activities of daily living and compensatory training, meal preparation, safety procedures, and instruction in the use of assistive devices and adaptive equipment.
  • 97710: Therapeutic Exercises – To develop strength and endurance, range of motion, and flexibility (one or more areas, every 15 minutes)
  • 97542: Wheelchair Management – Includes evaluation, fitting, and training.
  • 97112: Neuromuscular Re-education – Interventions focused on restoring balance, coordination, kinesthetic sense, posture, and proprioception.
  • 97129: Cognitive Skills – Therapeutic interventions that focus on cognitive function (i.e. memory, attention, reasoning, executive function, problem-solving) or compensatory strategies to manage the performance of an activity (managing time or schedules, initiating, organizing, and sequencing tasks). This code is only used for the initial 15 minutes. Each additional 15 minutes is billed under 97130.

 

Modalities Codes

These codes are used to document the application of various modalities or physical agents to facilitate therapeutic goals. There are two different types: supervised and constant attendance. Supervised modalities do not require one-on-one contact during modality delivery. Supervised modalities are untimed services. Constant attendance modalities do require one-on-one contact with a provider. These constant attendance codes are timed.

Examples of supervised modality codes include:

  • 97014: Electrical stimulation therapy (unattended)
  • 97018: Paraffin bath therapy
  • 97022: Whirlpool/Fluidotherapy
  • 97024: Diathermy

 

Examples of constant attendance modalities include:

  • 97035: Ultrasound
  • 97032: Electrical Stimulation (manual)- Functional Electrical Stimulation (FES) or Neuromuscular Electrical Stimulation (NMES) while performing a therapeutic exercise or functional activity may be billed as 97032.

 

Orthotic and Prosthetic Management Codes

These services are related to the evaluation, fitting, and training of patients in the use of orthotic or prosthetic devices.

Examples include:

  • 97760: Orthotic management and training (initial encounter) – Includes assessment and fitting, training in wearing schedule/skin checks/functional use.
  • 97761: Prosthetic training (initial encounter) – Includes preparation of the stump, skin care, modification of prosthetic fit (revisions to socket liner or stump socks), and initial mobility and functional activity training.

 

Commonly Used Modifiers

CPT codes may include a modifier or a two-digit number added to the end of a CPT code that provides the insurer with more information.

  • KX Modifier: Indicates that services for the patient have met the annual Medicare capped amount, but that the provider claims medical necessity for continued care.
  • GA Modifier: Indicates that a provider believes that the service may not meet Medicare standards for medically necessary care and that an Advance Beneficiary Notice (ABN) is on file, allowing the provider to bill the patient if Medicare denies the claim.
  • 59 Modifier: Indicates that the service is separate and distinct from another service provided on the same day.
  • CO Modifier: Outpatient occupational therapy services provided in whole or in part by an occupational therapy assistant. Starting in 2022, these services were reimbursed at a reduced rate of 85% of the fee schedule.

 

Common Mistakes to Avoid

Coding mistakes can lead to payment issues or claim denials. The most common mistakes include:

  • Inaccurately recording treatment time
  • Providing insufficient documentation to support billed services
  • Miscoding interventions

 

CPT Code Updates and Revisions

In 2024, new CPT codes were added to recognize the importance of caregiver training. CMS describes these as “training in strategies or techniques to facilitate the patient’s functional performance in the home or community”. The new codes allow caregiver training to occur without the patient present. Historically, services provided when the patient is not present have not been covered, so this addition is a significant change to their policy.

The three new CPT codes for caregiver training are:

  • 97550: 30-minute caregiver training code
  • 97551: 15-minute follow-up code
  • 97552: a group caregiver training code for multiple caregivers

 

Frequently Asked Questions:

Can I bill for documentation time?

No, there is no reimbursement for documentation specifically for writing evaluations, discharges, or progress notes. You may complete point-of-service documentation with the patient present; however, depending on your setting and area of practice this may be challenging to do effectively.

The right technology can help you document faster while focusing on care. Fusion is a comprehensive EMR that can help occupational therapists with point-of-service documentation by providing a user-friendly interface that allows them to easily input and access client information during treatment sessions.

Fusion offers customizable templates and forms specifically designed for occupational therapy, enabling therapists to efficiently document their observations, interventions, and progress notes in real-time. This streamlines the documentation process, reduces the need for duplicate data entry, and ultimately saves time for the therapists, allowing them to focus more on patient care. Additionally, Fusion’s mobile capabilities allow therapists to complete documentation on the go, further enhancing flexibility and convenience in point-of-service documentation. Schedule a demo today to see how Fusion could cut your documentation time in half.

 

How often are CPT codes updated?

They are updated annually, effective January 1 of each year. AMA will typically disclose this information in the fall to give clinics time to adjust and prepare for the new policy.

 

How can I bill for my services when I am working with another discipline such as PT or SLP in an inpatient setting?

Therapists working together to treat a patient cannot each bill separately for the same or different service provided at the same time. An example from CMS is “if an OT and PT are co-treating a patient with sitting balance and ADL deficits for 30 minutes, then only 2 units total can be billed to the patient: either 2 units of OT only; 2 units of PT only; or 1 unit of OT and 1 unit of PT.”

 

Where can I find more resources for CPT coding?

The Center for Medicare and Medicaid Services website is a good resource for the most updated information. AOTA also has some great resource videos at https://www.aota.org/practice/practice-essentials/coding.

 

 

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