Working as an occupational therapist or occupational therapy assistant can be incredibly rewarding. Through therapeutic exercises, dynamic activities, and manual therapy techniques, providers can help patients restore functional and cognitive performance.
Many occupational therapists say patient contact is the best part of the job, but very few enjoy figuring out occupational therapy billing codes. Occupational therapy’s current procedural terminology (CPT) codes can be quite complex, and the codes for occupational therapy can change at the drop of a hat.
Why is learning accurate occupational therapy CPT codes so important? The following are a few reasons to study billing codes:
- Your practice relies on using the proper CPT code descriptions to designate services provided, which ensures the insurance company reimburses you accordingly.
- If your office provides Medicaid services, using the right evaluation CPT codes ensures healthcare providers won’t run into trouble with this government program.
- Using the correct procedure codes ensures proper billing for services rendered, which means happier patients overall. This is especially important for private payers.
- Correct codes allow providers to perform a comprehensive assessment of patients and fully understand their medical history.
- Using proper codes for occupational therapy evaluations allows providers to contribute quality healthcare data, which informs sector trends, safety procedures, and adaptive responses.
Understanding Occupational Therapy Billing
Billing for occupational therapy evaluation, therapeutic exercise, and other services involves submitting accurate CPT codes to insurance companies. It is important to stay updated with the latest codes because they can change often, which means the codes used today aren’t the same codes you may have used five years ago.
Providers must submit the correct occupational therapy evaluation CPT or re-evaluation codes for their physical therapy services. Failing to do so means insurance companies will not reimburse an occupational therapy practice for its work.
The Impact of Accurate Billing on Occupational Therapy Practices
Accurate billing can promote adaptive responses and ensure insurance companies reimburse occupational therapy providers for their services. These CPT codes can also help practices perform a detailed assessment of environmental demands, work-task analysis, and money management.
Your occupational therapy clinic must use the correct CPT codes for all services involving patient contact, including manual lymphatic drainage, re-evaluation, group therapy, and sensory processing. Billing mistakes commonly lead to claims denials. For instance, if you use the same code for two different physical therapy services, the insurer might deny you for duplicate claims.
Deciphering Common Occupational Therapy Billing Codes
CPT codes for occupational therapy treatment options can be confusing, but your practice needs to understand each CPT code well. Common terminology associated with billing includes the following:
Pre-treatment time: including time spent on evaluation and re-evaluation, asking questions, and analyzing results
Intra-treatment time: this includes time spent performing treatments, such as pragmatic functioning therapy and teaching compensatory strategies
Post-treatment time: this includes assessing the client’s response to treatment and communicating with the patient, their family members, and other healthcare providers
Common CPT Codes in Occupational Therapy
The list of CPT codes relevant to occupational therapy is extensive, so it is not possible to go into detail on each one here. Instead, we’ll discuss some of the most common occupational therapy CPT codes, which include:
|Therapeutic procedure, one or more areas, to develop range of motion, flexibility, strength, and endurance
|Manual therapy techniques
|Community/work reintegration training
The American Medical Association has made several changes to CPT codes for 2023. For instance, some of the codes it has deleted include 99241 and 99251 for consultations, CPT code 99318 for nursing facility services, and CPT code 99343 for home or residence services.
The Importance of Evaluation Codes
CPT codes are split into low, moderate, and high complexity depending on occupational profile. A low-complexity occupational therapy (CPT code 97165) evaluation includes one to two elements, while a moderate-complexity evaluation (CPT code 97166) has three to five elements. A high-complexity occupational therapy evaluation (CPT code 97167) has five or more performance deficits. To determine the appropriate level of complexity, you must conduct an occupational profile.
Let’s go over a typical occupational therapy evaluation. Bob hit his head at work, and now he’s feeling dizzy. He’s also suffering from occasional headaches, and he suspects he may have damage to his cognitive function.
After conducting an occupational profile assessment of Bob’s functional performance and medical history, you conclude that this is a moderate complexity evaluation. That’s because you’ve identified three elements during this occupational therapy evaluation:
- Bob is dizzy.
- Bob has headaches.
- Bob isn’t thinking as clearly as he used to.
Navigating Complex Cases in Occupational Therapy Billing
When it comes to occupational therapy CPT codes, not every case is cut and dry. Occupational therapists may perform multiple services in one session, which would require the use of several different occupational therapy CPT codes.
It’s also important to be aware of time-based CPT codes for your treatment options. We’ll discuss these codes in more detail below.
Time-Based Codes and the “Eight-Minute Rule”
There are two types of CPT codes: time-based and service-based. Providers use service-based codes for primary procedure services, such as conducting an occupation-based assessment or re-evaluating a patient’s medical status. Providers can only bill one unit per code.
Time-based codes, on the other hand, allow providers to bill multiple units in 15-minute increments. A time-based CPT code is suitable for procedures requiring constant patient contact, such as therapeutic exercises, ultrasound, sequencing tasks, and executive function compensatory training.
If you accept Medicare, you must understand the eight-minute rule. Per this rule, to bill one unit of a timed CPT code, you must perform a service for at least eight minutes.
Avoiding Common Pitfalls in Occupational Therapy Billing
Insurance companies may deny claims for many reasons. Here are some common problems occupational therapists might run into when using billing codes and how to solve them.
|The insurance company doesn’t think a procedure is medically necessary.
|Be specific when describing the patient’s condition and assign CPT codes to the highest level of specificity.
|The patient’s insurance doesn’t cover a certain procedure.
|Ensure the patient’s insurer reimburses for the procedure before providing services.
|The required modifier is missing or wrong (denial code CO-4).
|Double-check the modifier, update as needed, and resubmit the claim.
|Incorrect diagnosis code (denial code CO-11)
|Double-check patient records for typos and resubmit the claim. However, if you used the correct CPT code, you may file an appeal.
The Role of Documentation in Successful Billing
Without proper documentation for each CPT code, insurance companies can deny claims. For this reason, most providers document patient encounters using the SOAP format, which stands for subjective, objective, assessment, and plan. Let’s go over each step in a bit more detail.
Subjective: Depicts the patient’s statements about their symptoms. This includes how often symptoms occur, their severity, and how long the problem has been happening.
Objective: Refers to measurable, quantifiable information, such as:
- Vital signs
- Imaging diagnostics
- Lab reports
- Physical exam findings
Assessment: Combines information from the subjective and objective stages. Providers use this information to make a diagnosis.
Plan: This stage serves as a conclusion to documentation. It can include:
- Testing to perform, along with next steps, depending on whether results are positive or negative
- How often the patient needs follow-up visits
- Therapy and medications required
Weave’s Role in Occupational Therapy Billing
If you need help staying on top of billing for your occupational therapy clinic, we invite you to try Weave! Our software allows you to handle billing with ease so you can get paid faster. With features like online bill pay, digital forms, and insurance verification, you’ll have more time to focus on the bigger picture (like deciphering that latest CPT code change).
Learn How Weave Can Help Occupational Therapists Manage Billing
If you hope to succeed in the crowded occupational therapy industry, your practice can’t go without learning and mastering today’s occupational therapy billing codes. Staying on top of the latest CPT codes can be time-consuming, though, especially when you have a busy practice to run.
Weave is your ticket to boosting the efficiency of your practice. Weave offers everything you need to successfully run your office, including online scheduling, practice analytics, appointment reminders, and convenient payment options.
To learn more about how Weave can help your practice with occupational therapy billing, request a free demo of our software now.
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