New codes support reimbursement for caregiver training
Occupational therapy practitioners (OTPs) have long understood the importance of caregiver training to facilitate the effective carryover of patient-focused skills, strategies, and safe transitions from skilled OT services to caregiver-assisted home programs. Getting reimbursed for this service can be challenging, however, especially in situations where the patient is not present for the caregiver training either due to the caregiver's schedule or patient factors that make patient attendance during caregiver instruction contraindicated.
Following extensive collaboration, AOTA, the American Physical Therapy Association (APTA), and the American Speech-Language-Hearing Association (ASHA), along with member experts from all three organizations, rose to this payment challenge by developing three new codes that capture training provided to caregivers without the patient present and successfully advocated with the American Medical Association (AMA) for inclusion of these new codes in the Current Procedural Technology (CPT) code set beginning January 1, 2024.
Coding for caregiver training
When the patient is present for the intervention, caregiver training is covered under the CPT code that most appropriately describes the education or training activity and the patient-centered goal it addresses.
Previously when the patient was not present, however, caregiver training was not able to be captured in coding for reimbursement because most CPT codes commonly used by OTPs are defined as 1:1 services that require direct patient interaction. While patient engagement in caregiver training is best practice in most scenarios, there are situations where the patient’s presence at the caregiver training may impede caregiver skill acquisition, negatively impact the practitioner-patient relationship, or the patient’s medical condition may be such that they are physically or cognitively unable to participate in the caregiver session.
Effective January 1, 2024, these new CPT codes enable OTPs to capture and bill for planned and coordinated training sessions provided to one or more caregivers for an individual patient or groups of caregivers for several patients, without the patient(s) present, when the focus of the caregiver training relates directly to the patient goals and outcomes.
New caregiver training CPT codes
9X015* Caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem-solving, safety practices) (without the patient present), face-to-face; initial 30 minutes
9X016* each additional 15 minutes (List separately in addition to code for primary service) (Use 9X016 in conjunction with 9X015)
9X017* Group caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem-solving, safety practices) (without the patient present), face-to-face with multiple sets of caregivers
*CPT code numbers pending Medicare Physician Fee Schedule and AMA finalization at this time.
Payer advocacy success
Access to CPT coding is not the same as payment for these codes. Each payer sets its own payer policies around which CPT codes OTPs may bill for reimbursement. AOTA is excited to announce that, as a result of joint advocacy efforts by AOTA, APTA, and ASHA, the Centers for Medicare and Medicaid Services (CMS) has acknowledged the importance of caregiver training to support patient outcomes and proposed Medicare Part B payment for these services at the values agreed upon during the AMA code valuation process.
This important advocacy win supports reimbursement for a critical aspect of occupational therapy service delivery that could have a direct impact on client outcomes and demonstrates the high value of occupational therapy services specifically for Medicare patients and their caregivers as the Medicare-age population continues to grow.
Additional resources on how to code, document, and bill these new CPT codes are in development. Keep an eye on AOTA’s website for more information as it becomes available.