Coding & Billing

Content Menu 

Watch Videos on YouTube

DMEPOS Training

Modifiers Training

CPT and ICD10 Basics Training

Cognitive Intervention, New CPT Codes for 2020

The Occupational Therapy Assistant Modifier: What it is and When to use it

Coding a New Occupational Therapy Evaluation

Coding an Occupational Therapy Re-Evaluation

Understanding Time Based Billing

Coding

Coding is essential not only for proper reimbursement, but also because it is used as a tracking tool by CMS and other agencies to inform how occupational therapy is practiced. These tips will help guide the selection of the most appropriate evaluation and intervention codes.

Occupational Therapy Evaluation and Re-Evaluation Codes

CPT® Evaluation Codes

An occupational profile is required for every evaluation. It is the starting point to determine what treatment is needed. An occupational profile should include the client’s occupational history, concerns, reasons for referral, and the client’s goals. 

History includes reviews of related medical conditions and previous therapy history.  

The three levels of the Occupational Profile and history component are broken down into brief, expanded, and extensive. A brief history looks at the presenting problem alone. Expanded and extensive also take into account related physical, cognitive, and psychosocial concerns, and therapy history. Extensive differs from expanded in the amount of information documented and the number, length, and severity of comorbidities. 

Performance deficits should be considered occupations. A complete list of occupations can be found in the Occupational Therapy Practice Framework: Domain & Process. This approach does not discount performance skills deficits; rather, the skills should be outlined in terms of the occupations that are affected. Keep in mind that this process is being performed as a means of determining what occupations will be addressed in the plan of care, so everything should be reviewed using that context. 

A low complexity evaluation examines 1–3 deficits, moderate examines 3–5 deficits, and high examines 5 or more deficits. 

Clinical decision making requires you to use your clinical judgment in determining whether the complexity is low, moderate, or high. Low complexity generally is an analysis of a problem-focused assessment with limited treatment options and no comorbidities. Moderate complexity includes analysis of a detailed assessment with several treatment options, and possibly comorbidities. Some modification of tasks may be required to complete the evaluation. High complexity includes analysis of a comprehensive assessment with multiple treatment options and comorbidities affecting performance. Significant modification of tasks is required to complete the evaluation. 

Re-Evaluation

The CPT® requirements for a re-evaluation include an assessment of changes in patient functional or medical status, an update to the initial occupational profile that reflects changes in condition that affect goals, and a revised plan of care. The requirements go on to specify that a formal reevaluation is only performed when there is a documented change in functional status, or a significant change to the plan of care is required. The key is a significant change. That change can be in functional status or in the plan of care itself. It can be based on new clinical findings or a patient’s failure to respond to treatment. Each insurance carrier will have its own guidelines as to when a re-evaluation is appropriate, so be sure to check with the payer.

CPT® EVALUATION RESOURCES

ICD-10 Resources

The ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) system, replaced the ICD-9-CM (9th Revision) on October 1, 2015. AOTA developed the following resources to help occupational therapists deal with the continuing challenges of ICD-10-CM.

Diagnosis Code Selection

The treating diagnosis is not always the primary medical diagnosis. Use the diagnosis that most appropriately describes the condition you are treating. More than one diagnosis may be appropriate. Do include any comorbidities that are affecting treatment. If possible, avoid unspecified codes.

ICD-10 CODING RESOURCES

CPT Coding Resources (Procedure Coding)

Interventions

Intervention CPT® codes are deliberately non-specific so that they can apply to various types of therapeutic scenarios. Therefore, in choosing an intervention code, the intent of the intervention should be a driving factor. What are you trying to achieve therapeutically? A complete list of commonly used occupational therapy CPT codes can be found on the AOTA website.

Orthotics

CPT® codes for orthotic and prosthetic management and training can be used for orthotic evaluation, selection, fabrication, and training. 

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. 

Supplies can be billed with 97760 and 97761 if an orthotic is fabricated. If also billing an L code for the orthotic, 97760 and 97761 should only be used when training is completed and training alone exceeds 8 minutes. 

97763 should be used for all subsequent encounters for modifications, fitting adjustments, and additional training regardless of whether the orthotic is custom made or prefabricated. 

Remember, these are time-based codes. More than one unit can be billed based on the amount of time spent face to face with the client. Also, these services must be properly documented to include not only time spent but what was fabricated, adjusted, or trained; the reason for the fabrication, adjustment, or training; activities or exercises performed in the orthotic; a description of the client’s condition; and the client’s response. 

Orthotic management cannot be billed on the same day as an evaluation. It can be used for the fabrication of a custom splint. Supplies can be billed in addition to the management code. If you choose to use HCPCS L codes to bill for the orthotic, you cannot bill for orthotic management. 

If the orthotic is not fabricated on site, it will most likely have an appropriate L code for billing. Some practitioners will send the client to a supplier who will bill Medicare directly for the orthotic. Others may choose to keep a supply of these orthotics in the therapy clinic and bill Medicare when they are dispensed. 

For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient information about the patient’s medical condition to substantiate the necessity of the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient’s diagnosis and other pertinent information as applicable, such as duration of the patient’s condition; clinical course (worsening or improving); prognosis, nature, and extent of functional limitation; other therapeutic interventions and results; and past experience with related items.

HCPCS Level II Coding (Coding for Orthotics, Prosthetics and Durable Medical Equipment)

Timed Codes/8-Minute Rule

The 8-minute rule was devised by CMS to determine how to report billable units of timed services. Many, but not all, insurance carriers follow these same guidelines (some use different rounding rules). Use these guidelines for timed services only. If an untimed service is also billed the same day, do not count the time spent on the untimed service toward billable units. The following chart documents how many minutes must be provided in order to bill the corresponding number of units. Note how 1 billable unit for a timed code must be at least 8 minutes, and it does not increase to a second billable unit until you have at least 8 minutes past the 15-minute mark. If more than one timed CPT code is billed during a calendar day, then the total treatment time determines the number of units billed.

  • How to Reflect Practitioner Time in CPT Codes

Modifiers

  • Modifier 59 

Modifier 59 does not apply to all codes. Certain situations require the modifier to clarify that two services that would typically be considered part of the same service should both be allowed because in this instance they are performed as two separate and distinct interventions.

Points to Remember:

  • Modifier 59 should only be used when the two 15-minute timed services are performed sequentially. The time spent must be clearly documented as separate and distinct, and cannot overlap.  
  • For example, if you spent 7 minutes on therapeutic activities and 10 minutes on self-care, only one 15-minute unit can be billed. But if you spent 15 minutes on therapeutic activities and then an additional, separate 15 minutes on self-care, you would bill both codes and modifier 59 would be appropriate. 
  • Modifier GO 

Modifier GO Indicates that the service was performed under a therapy plan of care. It should be used on every service performed under a therapy plan of care billed to Medicare, Humana, and United Healthcare. 

  • Modifier CO 

Modifier CO is required whenever an OTA performs more than 10% of a service independently for Medicare, Tricare, and Humana. There are several scenarios where the modifier would apply: 

    • First, when the OTA performs the entire service or unit of service.  
    • Second, when an OTA performs more than 10% of a service independently. This works out to be more than 1.5 minutes of a 15-minute unit.  
    • Third, when the OTA performs more than 10% of an untimed service independently. This will require keeping track of the time spent during an untimed service. This modifier will signify a 15% payment reduction beginning in 2022. 
  • Modifier KX 

The KX modifier is meant to be placed on all services that exceed the Medicare yearly therapy threshold ($2110 for the year 2021. Using this modifier is an indication that the practitioner is aware the threshold has been exceeded, but the therapy services continue to be medically necessary. 

  • Modifier GA 

Modifier GA is used to let Medicare know that an ABN is on file for the service because the service is not believed to be covered by Medicare in these circumstances. 

  • Modifier 95/GT 

Modifiers 95 and GT are both used to indicate synchronous telehealth services. The payer will determine which modifier they prefer.

NCCI Edits

The Medicare National Correct Coding Initiative (NCCI; also known as CCI) was implemented to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Medicare Part B claims. NCCI Edits are updated quarterly to prevent improper payments when incorrect code combinations are reported.  

NCCI Edits only apply to Medicare Part B services. State Medicaid agencies and other third-party and commercial payers are also required to use CCI Edits but may modify them to meet their own programmatic needs. Please check with non-Medicare payers regarding their use of CCI Edits.

Commonly Used Codes for Children and Youth

Want to know more about the roles and responsibilities of the AOTA Coding Advisory Team?

Watch a video on understanding those roles and responsibilities and how you can get involved! 

For additional assistance with payment and reimbursement issues, contact AOTA’s Regulatory Affairs department at regulatory@aota.org.

Advertisement