You don’t have to be a pro athlete to know there are two primary components to training for a sport. First, there’s a daily regimen of exercises designed to condition and strengthen the muscles, providing a strong foundation. Second is an extensive amount of practice with the specific movements the game requires. This analogy can help us make sense of when to use each of the two most common occupational therapy CPT codes: 97110 and 97530.  

The 97110 CPT code describes therapeutic exercises that a patient participates in during an OT therapy session. These exercises help build strength or endurance to support a return to normal functioning. The 97530 CPT code describes therapeutic activities that are practiced during a session to improve functioning. These activities often include practicing real-life skills like transferring from a chair or bed. In this post, we’ll examine both codes in-depth, explain when to use them, and identify the billing documentation needed for each.

What is the 97110 CPT Code?

The 97110 CPT code describes foundational occupational therapy exercises that are designed to improve a patient’s strength, range of motion, endurance, or flexibility. They address issues with muscle weakness, stiffness, or a decreased range of motion. 

In order to bill, the exercises prescribed must be medically necessary to improve a patient’s strength and mobility to increase participation in activities of daily living, like bathing, dressing, feeding, and a range of other functional activities. You work with the client to complete these exercises, either actively, active-assisted, or passively. Another requirement to bill using the 97110 CPT code is that you must be actively working with the client one-on-one during the entire session. It’s a timed code, with each unit lasting 15 minutes. The 97110 CPT code describes exercises that address one deficit area across one or more areas of the body.

Read Understanding Occupational Therapy Billing Units to learn how to calculate billing units for timed codes.

When to Use the 97110 CPT Code

You’ll use this code when you’re working with a patient to complete sets of specially designed exercises that restore flexibility, strength, endurance, or range of motion. Examples of exercises that would typically carry this billing code include using free weights to increase arm strength or walking on a treadmill to build endurance. Other examples may include overhead stretches with a TheraBand to increase range of motion in an injured shoulder or using TheraPutty to build up hand strength after a stroke.

Required Documentation for the 97110 CPT Code

Documentation helps you provide better care to clients and, importantly for billing, justifies your services to insurers if you receive a claims rejection or undergo an audit. The documentation for billing 97110 typically identifies a single deficit area you’re targeting for treatment. It makes a clear connection as to how that deficit is negatively impacting the patient’s quality of life. Decreases in flexibility, range of motion, strength, and endurance are all examples of commonly used deficit areas. 

You should record an objective measure of the deficit area before beginning to work with the patient and update it as they progress through the course of treatment. Your documentation should include the area of the body you’re working on and the type, quantity, and purpose of exercises performed during your occupational therapy sessions. 

As the patient progresses, document any changes you made to their exercise program, including any new exercises added. You’ll want to clearly show that the client is making objective, measurable improvements and that there is a clear, planned progression towards an eventual transition to a home exercise program. For complex patients who require a higher level of care, billing for more than one unit can certainly be appropriate.

What is the CPT 97530 CPT Code?

The 97530 CPT code is used to document therapeutic activities intended to improve a patient’s functional performance due to lost or restricted mobility, coordination, balance, flexibility, or strength. What differentiates the 97530 CPT code from the 97110 CPT code is that it involves functional activities, not exercises. These activities provide very specific training for the activities of daily life that have been compromised. To use this code, you must be present with the patient for the entire session, working one-on-one with them in an active, active-assisted, or passive role. The 97530 CPT code is also a timed code, with each unit lasting 15 minutes, and it describes a therapy session that addresses multiple deficits through participation in a functional activity. 

When to Use the 97530 CPT Code

The 97530 CPT code is often the best choice when the session focuses on training that involves a functional activity. One example would include having a patient stand on a balance board while bending down or reaching up for objects at varying heights. Another might include having a client complete a fine motor task while they’re wearing cuff weights. 

Required Documentation for the 97530 CPT Code

Where the 97110 CPT code typically addresses just one deficit area being targeted by treatment, the 97530 CPT code most frequently focuses on two or more areas. These expected outcomes include things like improving balance, flexibility, strength, or other functional activities. Your documentation should include the areas you targeted for improvement and a detailed description of those activities. Explain why you chose these activities to remediate the deficit areas. Make a clear connection between the activity and its role in restoring a function of daily life. Include the level of assistance you needed to provide the patient during the activity. 

Read SOAP Notes for Occupational Therapy to take better documentation notes and speed up your process. 

Wrapping Up

At first glance, the 97110 and 97530 CPT codes look very much alike. Although they have similarities, there are some significant differences in how the occupational therapy is provided and the documentation required for each. Knowing when and how to use each will decrease your number of rejected claims and can simplify potential audits from insurers.

Check out our Complete Guide to Occupational Therapy Billing to learn more about how to simplify and improve your billing processes.

Occupational therapy evaluation codes are divided into three tiers based on complexity: low, moderate, and high. The complexity level of an evaluation is based on three areas: the patient’s profile and history, the assessment of occupational performance, and level of clinical decision making exercised by the occupational therapist during the evaluation. While this categorization seems straightforward, it can be challenging to know what constitutes low complexity, moderate complexity, and high complexity. In this post, we’ll walk through what to look for at each level to help you discern which CPT evaluation code best matches the service you performed. We’ll also cover the code for an occupational therapy reevaluation and its criteria. As we close out, we’ll look at three mistakes commonly made with occupational therapy evaluation billing codes.

What to Consider as You’re Choosing Evaluation Codes for Occupational Therapy

As we discuss each evaluation code, we’ll begin with the exact verbiage from the CPT Code Manual. From there, we’ll share practical markers to look for at each level of complexity. It’s important to note that to select the correct level of complexity, you must be sure all three areas meet the criteria for that evaluation level. For example, if an evaluation met the definition of a low level of complexity for both profile and history and assessment of occupational performance components, but the level of clinical decision-making was done at a moderate level, you would still be required to bill at a low level of complexity. 

Low Complexity Evaluation (OT 97165)

A low complexity evaluation takes the least amount of time and involves a relatively uncomplicated process of reviewing, evaluating, and creating a plan of care. Here’s the exact definition as found in the CPT Code Manual.

 

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(s) 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(s) is not necessary to enable completion of evaluation component.
  • Typically, 30 minutes are spent face-to-face with the patient and/or family.

Defining Characteristics of a Low Complexity Evaluation

Determining the correct type of occupational therapy evaluation requires sound professional judgment. While there’s no one-size-fits-all definition of what constitutes a low complexity evaluation, here’s a description you can judge by.

 

A low complexity evaluation begins with a brief review of the patient’s medical and/or therapy records related to the presenting problems. There are no comorbidities that impact the presenting problem. In this evaluation, you would use standardized assessments to identify up to three deficits in functional performance that result in the patient’s activities or participation being limited or restricted. The patient does not require modifications or assistance to complete the assessments. Performance deficits may be in the physical, cognitive, or psychosocial areas. When considering your menu of treatment options, you would include an analysis of the occupational profile and data from problem-driven assessments. A low level of analytical skills is required during this type of evaluation. 

Moderate Complexity Evaluation (OT 97166)

An occupational therapy evaluation of moderate complexity is a mid-tier evaluation. According to the CPT Code Manual, an evaluation of moderate complexity needs to include the following characteristics. 

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(s) 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(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. 
  • Typically, 45 minutes are spent face-to-face with the patient and/or family.

Defining Characteristics of a Moderate Complexity Evaluation

During a moderate complexity evaluation, you would begin with a more in-depth review of the patient’s medical and/or therapy records. You would also complete a secondary review of the patient’s relevant physical, cognitive, and psychosocial history. The patient may have comorbidities affecting their occupational performance. Using standardized assessments, you would identify three to five deficits in the areas of physical, cognitive, or psychosocial ability. The patient may require minor to moderate modifications or assistance when completing the assessments. Performance deficits may be in the physical, cognitive, or psychosocial areas. You may develop an expanded range of treatment options using the occupational profile and data from problem-driven assessments. Analytical skills are exercised at a moderate level.

High Complexity Evaluation (OT 97167)

An evaluation at the highest level of complexity is typically done with a patient exhibiting multiple impairments and complex medical history. The CPT Code Manual states an evaluation of high complexity must satisfy each of the criteria listed below.

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 additional review of physical, cognitive, or psychosocial history related to current functional performance; 
  • An assessment(s) that identify 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • A clinical decision-making is of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.
  • Typically, 60 minutes are spent face-to-face with the patient and/or family.

Defining Characteristics of a High Complexity Evaluation

During a high complexity evaluation, you would conduct an in-depth review of the patient’s medical and/or therapy records, including a thorough review of the patient’s relevant physical, cognitive, and psychosocial history. The patient has comorbidities that are impacting occupational performance. Using standardized assessments, you would identify five or more physical, cognitive, or psychosocial performance deficits. The patient requires a significant level of modifications or assistance to complete the assessments. Performance deficits may be in the physical, cognitive, or psychosocial areas. Extensive data from various sources, including the patient’s occupational profile and a range of problem-focused assessments, requires a high level of analytical skills to develop several treatment options.

Reevaluation (OT 97168)

Unlike the three-tiered system of occupational therapy evaluation codes, the reevaluation is just a single code. Compared with the evaluation codes, the criteria found in the CPT Code Manual are relatively simple.

Reevaluation 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.

Defining Characteristics of a Reevaluation

The reevaluation isn’t broken down into levels of complexity like the evaluations are. A reevaluation is typically conducted when there is a new clinical finding, a substantial change in the patient’s functioning, or when the patient is not responding to the current therapeutic interventions. 

Common Mistakes with Occupational Therapy Evaluation Coding

When billing for occupational therapy evaluations, it’s easy to make mistakes. Incorrectly coding the complexity level of an evaluation can result in your claim being denied, and having to make the necessary corrections and resubmit the claim wastes time and can delay your reimbursements. So you’ll want to avoid mistakes when possible. Here are three of the most frequently made occupational therapy billing mistakes.

  • Undercoding — If you’re not thoroughly familiar with the criteria for each level of occupational therapy evaluation, you may inadvertently be undercharging for services you’ve performed. Knowingly undercoding isn’t a way to protect your practice from audits, and it’s actually considered unethical.
  • Overcoding — On the flip side, overcoding puts you at risk of an insurer denying your claim if the level of evaluation you’re claiming seems excessive. Remember, each of the three main areas of the evaluation must meet the criteria for the highest level of evaluation you’re claiming.
  • Incomplete Documentation — If an insurer challenges one of your billing claims or if your practice is audited, having documentation to back up the level of service you’re claiming is essential. Your therapy notes must be able to objectively prove that you provided the service you’re billing for.

In Conclusion

Billing an insurer for a higher level of complexity than your documentation can support may result in a billing claim being rejected. Choosing a code that’s at a lower complexity than you actually performed will result in being underpaid for your services. By understanding the CPT code descriptions, you’ll be able to bill with confidence, knowing you’re getting properly compensated and can back up your claim with sound reasoning.

Check out our Complete Guide to Occupational Therapy Billing to learn more about how to simplify and improve your billing processes.

Because there are many different occupational therapy ICD-10 codes, some of which are quite similar, it can be challenging to know which to use when assessing and treating patients. This post will explore the common mistakes to avoid when assigning ICD-10 codes and tips for selecting the most accurate code for billing purposes. We’ll close with a list of common ICD-10 codes that occupational therapists use most frequently.

What is ICD-10 Coding?

ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems. This framework is the World Health Organization’s medical and therapeutic classification system. It’s a standardized system that allows medical and therapy professionals to code a wide variety of diseases, external causes of injury, treatment of conditions, and more. 

 

The United States was the last country with a modernized health care system to adopt ICD-10 coding standards. On October 1, 2015, the U.S. officially moved away from ICD-9, the older code set that had been in use since 1979. The use of ICD-10 is now mandatory for all entities covered under HIPAA. 

 

ICD-10 codes are a combination of three to seven alphanumeric characters. There are two types of ICD-10 codes: medical diagnosis codes and treatment diagnosis codes. The patient’s physician assigns medical diagnosis codes. A therapist can assign treatment diagnosis codes. ICD-10 codes don’t replace CPT codes — it’s important to note that you much include them both on billing claim forms.

Common ICD-10 Coding Mistakes

The move to ICD-10 was a double-edged sword for occupational therapists. The new code set contains over five-and-a-half times more codes than its predecessor. More specific codes allow you to select the code that accurately and clearly describes a patient’s current deficit area. But with more similar-but-slightly-different codes available, the chances of incorrectly coding a treatment diagnosis have increased. Here are some of the most common ICD-10 coding mistakes and how to avoid them.

Using Outdated Codes

ICD-9 was replaced in 2015. Although it’s been several years, if you were familiar with the old way of coding, it may be easy to inadvertently revert to outdated codes, especially if you’re rushing or tired. If you use an old code, your chances of an insurer rejecting your billing claim are all but assured. 

Confusing Similar Letters and Numbers 

ICD-10 codes are made up of alternating series of letters and numbers, separated by periods. If you’re not paying close attention or are in a hurry, it’s easy to place an O where a zero should be or swap a 1 for an I. Accidentally subbing in the wrong letter or number in a coding sequence can change the therapeutic diagnosis code entirely, sending up a red flag to insurers as they process your claim. 

Leaving Out Laterality and Specificity 

ICD-10  focuses heavily on identifying the laterality and coding to the highest specificity. This focus can make finding the best code a little more time-consuming. But finding the code that’s the best fit for the therapeutic diagnosis and designates which side of the body is affected will help you avoid rejections or denials. 

Selecting an Incorrect Code 

Lack of familiarity with the full menu of ICD-10 codes that could describe a particular diagnosis can result in choosing the wrong code. You don’t have to know them all, but being well-versed in the codes most frequently used with occupational therapy patients can help avoid time-consuming resubmissions.

Incomplete Documentation  

If you enter a treatment diagnosis code, you need to have documentation to justify your choice. Keeping detailed notes of your therapy sessions and recording data from objective assessments of their current levels of functioning makes it easier to justify your choice if it’s ever challenged by an insurer.

Tips for Choosing the Best ICD-10 Code for Occupational Therapy

When you choose the wrong ICD-10 code, incorrect information about a patient goes on the record, making it difficult to show the medical necessity of the treatment you provided. This can lead to billing claims rejections, time-consuming resubmission, and payment delays. Here are some helpful tips to ensure you choose the best ICD-10 code for every patient the first time.

Begin with Documentation 

Assess your patient’s impairments using objective measures and document their current level of functioning in the area you’ll be providing service. Create and document your short and long-term goals for the patient related to the targeted impairment and include them as part of the patient’s plan of care. Select your treatment codes, consulting the code definitions to ensure they match up with the impairment.

Be Sure Treatment is Medically Necessary for the Diagnosis

The code you choose must be medically necessary and directly relate to the service you provided to the patient.

Use Therapy Notes to Support Your ICD-10 Code Choice

Documentation from your therapy notes should support your ICD-10 coding choice. Include information such as dominant side, anatomical details, site specificity, and the affected body part.

Order the Codes by Amount and Complexity of Care

As mentioned before, code to the highest level of specificity, including all of the patient’s current medical conditions and comorbidities related to the current therapy services you’re providing. Order the codes sequentially by the amount and complexity of therapy being provided.

Use Unspecified Codes Sparingly 

There’s certainly a place for using unspecified codes if there’s insufficient information in the patient’s medical record. But unspecified codes tend to get overused in favor of less common, but more specific codes. Using an unspecified code too often can be a red flag for insurers.

Commonly-Used OT ICD-10 Codes

Some ICD-10 codes are more commonly used by occupational therapists than others. Here are ten codes you’re likely to come back to again and again.

  • R63.3 — Feeding difficulties
  • G54.0 – Brachial Plexus disorders
  • R62.0 — Delayed milestones in childhood
  • G82.20 — Paraplegia unspecified
  • R27.0 — Ataxia, unspecified
  • F82 — Specific developmental disorder of motor function
  • M62.81 — Muscle weakness (generalized)
  • F88 — Other disorders of physiological development
  • M25.60 — Stiffness of unspecified joint, not elsewhere classified
  • F81.9 — Developmental disorder of scholastic skills, unspecified 

Wrapping Up

ICD-10 is the most comprehensive diagnostic coding system to date. It gives occupational therapists the freedom to select diagnostic codes that include a high level of detail about their patient’s condition. But with expanded choices comes an increased risk for coding mistakes. By paying careful attention, becoming familiar with the codes most often used by occupational therapists, and keeping good documentation, you’ll be able to avoid many of the common ICD-10 coding pitfalls.

Check out our Complete Guide to Occupational Therapy Billing to learn more about how to simplify and improve your billing processes.

To err is human. But making errors on your claims forms can result in delayed or denied reimbursements. From clerical mistakes to inaccurate coding, there are many ways that billing trips up therapists handling their own claims. This post will explore some of the most common mistakes in occupational therapy billing and share how to avoid them so you can improve your acceptance rate and get paid faster.

General Errors in Occupational Therapy Billing

General billing errors are the easiest to avoid. You can prevent these errors by paying close attention to the information you record on your patient data, claims forms, and therapy notes. 

Clerical Errors

Incorrectly spelling a patient’s name or entering the wrong date of birth significantly raises the chances of an insurance claim rejection. Simple mistakes like entering the incorrect insurance provider details can be time-consuming to fix. Rushing through the claims submission process rarely saves time in the long run. 

Duplicate Billing 

If two staff members file a claim, both claims will likely be rejected. Make sure everyone is on the same page about who’s responsible for filing claims. Having a clear division of labor in your office will help prevent this error. 

Insufficient Documentation

Insurers want proof that you’re providing the services you’re billing for. Your claims form should include the patient’s diagnosis with their presenting problems and the services you provided. If you’re asked to provide documentation describing your reasoning for choosing the treatment, you’ll need to be able to present it.

Did you know you can sometimes bill for the time you spend doing documentation? Learn more by reading When Can Pediatric Therapists Bill for Documentation Time?

Coding Errors in Occupational Therapy Billing

CPT codes are the language of insurance billing. When you use an incorrect code, the intended message gets lost in translation. Let’s examine some of the most common CPT coding missteps.

Upcoding or Undercoding

Upcoding is coding for a higher-paying treatment than was actually performed. Undercoding is the opposite — it involves coding for a lower-paying treatment than you delivered. Upcoding can be used to generate higher payments from insurers. While it may be an innocent mistake, insurers take it seriously. Intentional undercoding is sometimes used to avoid audit scrutiny or to save a patient money. Both practices are unethical.

Using an Incorrect CPT Code

With so many CPT codes to choose from, it’s easy to select the wrong one. Using an incorrect CPT code exponentially increases your chances of a claims rejection or denial. Even if your billing claim is paid, incorrect information may become part of your patient’s billing record, so it’s important to avoid incorrect codes. 

Incorrect Use of Modifiers

Billing modifiers supply additional information about the type of service that you performed. Modifier 59 is one of the most commonly used. This code indicates that two services that would typically be billed together were provided independently and should be reimbursed as separate interventions. If you use a billing modifier, make sure the services provided match the modifier’s intended use. 

Unbundling Codes

Unbundling involves billing for two services separately that are usually billed together as a bundled service. In most instances, bundled codes must be used for a combination of services performed in the same session, rather than coding the services separately. 

Overusing Codes

Overreliance on a single CPT code is a red flag to insurers, and rightly so. In any occupational therapy practice, therapists provide a broad menu of services. It may be tempting to reach for your old standby, but locating the CPT code that best represents the diagnosis or intervention you provided is always the right choice.

Exceeding the Capped Daily Maximum for Fixed Rate Payers

Fixed rate payers like Medicare have a capped daily maximum payment. If you provide services that exceed this amount, you won’t be paid for any services you rendered beyond the maximum. 

Undertiming a Therapy Session 

Keeping accurate records of how long you spent in a session ensures you’re able to bill for timed codes accurately. Guesstimating can result in billing for one unit rather than the two you were entitled to. Gradually, the cost of undertiming sessions will add up.

Not Coding for Telehealth-Based Services 

Telehealth-based services have experienced a rapid expansion in 2020. Some insurers require the use of a CPT modifier when billing for services provided via telehealth. As a general rule, Medicare providers and private insurers require the 95 modifier to indicate the service was provided via telehealth. 

How to Avoid Coding Errors

The good news about billing errors is that they’re avoidable. The time you spend tightening up your practice’s billing procedures and building a deeper knowledge of billing-related issues will pay off many times over. Here are three best practices that will help you prevent errors.

  • Train Your Staff — The importance of a well-trained staff cannot be overestimated. Periodic training for office staff responsible for billing helps to calibrate everyone’s efforts and makes it easier to correct potential issues quickly. 
  • Stay Current on CPT Codes — CPT codes and the guidelines that govern their use change frequently. Keeping up with what’s new ensures your billing claims use the most up-to-date information.
  • Look for Patterns in Claims Rejections and Denials — Claims rejections and denials happen to even the most careful billers. Look for common reasons why your office’s claims are rejected or denied. They may vary by insurer, so pay close attention to any themes you see. Recognizing patterns can help you right the ship quickly.

Use Software Technology to Avoid Errors

Occupational therapy billing is a complex process, and it’s easy to make mistakes. But because coding correctly the first time is essential for prompt payment, you’ll want to ensure you avoid errors. Using a good practice management software that automates much of the process will help. With software, you can store information digitally and auto-populate your claims forms. You can also see an updated list of codes that apply to your services.

See how Fusion’s practice management system can help you improve your claims acceptance rate. 

Check out our Complete Guide to Occupational Therapy Billing to learn more about how to simplify and improve your billing processes.

While billing can be intimidating if you’re new to it, there’s no reason to fear handling your own billing. Being your own biller gives you complete flexibility and allows you to control the entire client-practice relationship. You can also ensure compliance more easily since you’re aware of everything that’s being done. 

This guide explores the essentials you need to know about occupational therapy billing practices. We’ll cover the most common billing errors and how to avoid them. We’ll then take a deep dive into occupational therapy evaluation CPT codes and the criteria required to bill for each. We’ll wrap things up with a look at best practice tips for selecting the right ICD-10 codes.

Common OT Billing Mistakes

Errors with occupational therapy billing can be costly. When claims are rejected, payment for services is delayed, robbing your practice of the operating capital it needs to thrive. Mistakes with coding can also result in incorrect information being added to a client’s billing record, being paid less compensation than you’re owed, or being flagged for an audit by an insurer. Here are some of the most frequently-made billing mistakes and how to steer clear of them.

General Errors and How to Avoid Them

Mistakes in this category are usually a result of carelessness, and they’re easy to avoid. 

  • Clerical Mistakes — Misspelling a client’s name, entering an incorrect date of birth, or transposing a number or letter in the patient’s policy ID number are all examples of clerical errors. These honest mistakes are a hassle to correct and often result in payment delays. Slowing down enough to fill out and submit a billing claims form correctly the first time is always a time-saver.
  • Double Billing — Submitting the same claim twice all but guarantees a claim will be rejected. Delineate billing responsibilities in your office, so there’s no confusion about who’s submitting claims for reimbursement.
  • Missing Documentation — If you don’t include adequate information, you may be asked to resubmit the claim. Including all the information required on the initial claims form will reduce rejections and denials.

Coding Errors and How to Avoid Them

Coding mistakes are more difficult to prevent since they’re usually a result of not understanding the OT CPT codes. But you can use best practices to avoid them.

  • Upcoding — As the name implies, upcoding involves using a billing code that exceeds the patient’s current diagnosis or the level of treatment you provided. At times, upcoding can be the result of misunderstanding the criteria for billing that code. Reading the CPT code description found in the CPT Code Manual can increase the accuracy of your coding. Upcoding is illegal, so getting this right is essential. 
  • Undercoding — The opposite of upcoding, undercoding is reporting a diagnosis or procedure that’s less intensive than reality dictates. Undercoding can result from an honest mistake or an attempt to save a patient some money or avoid an audit. Undercoding is not ethical, so be sure you’re accurately billing at the patient’s actual level of need.
  • Overusing Codes — When it comes to billing, there’s no lack of CPT codes to choose from. It can be tempting to use the same codes over and over again for convenience. But this practice may invite an audit from an insurer and doesn’t provide an accurate reflection of the services you’re delivering. 
  • Not Including Telehealth Modifiers — Providing telehealth services often requires the use of a modifier. Medicare and private payers typically want therapists to include the 95 modifier to indicate a service was provided via telehealth.

See Common Mistakes in Occupational Therapists Make When Billing for more mistakes and how to avoid them. 

OT Evaluation CPT Codes

Occupational therapy evaluation codes are broken into three tiers based on the level of complexity. Each one has a corresponding CPT code. An occupational therapy reevaluation has a single CPT code. Below is a brief snapshot of what an evaluation at each level would typically involve. 

Low Complexity Evaluation (OT 97165)

  • This evaluation requires only a brief review of the patient’s medical and/or therapy records related to the current presenting problem.
  • The patient has no comorbidities impacting the presenting problem. 
  • The therapist identifies up to three deficits in functional performance that result in a patient’s activities being limited or participation restricted using problem-driven standardized assessments.
  • No modifications or assistance from the therapist are required to complete the assessments. 
  • Deficits in performance may be physical, cognitive, or psychosocial. 
  • Analysis of the patient’s occupational profile and data from assessments is used to formulate a small number of treatment options. 
  • The evaluation requires a low degree of analytical skills to complete. 

Medium Complexity Evaluation (OT 97166)

  • This evaluation requires an in-depth review of the patient’s medical and/or therapy records, including a secondary review of the patient’s relevant physical, cognitive, and psychosocial history. 
  • The patient may have comorbidities that impact their current level of occupational performance. 
  • The therapist identifies three to five deficits in the areas of physical, cognitive, or psychosocial ability using problem-driven standardized assessments. 
  • Minor to moderate modifications or assistance from the therapist may be required to complete the assessments. 
  • Deficits in performance may be physical, cognitive, or psychosocial. 
  • Analysis of the patient’s occupational profile and data from assessments is used to formulate an expanded range of treatment options. 
  • The evaluation requires a moderate degree of analytical skills to complete.

High Complexity Evaluation (OT 97167)

  • This evaluation requires an intensive review of the patient’s medical and/or therapy records, including a thorough examination of the patient’s relevant physical, cognitive, and psychosocial history. 
  • The patient has comorbidities that are impacting occupational performance. 
  • The therapist identifies five or more physical, cognitive, or psychosocial performance deficits using problem-driven standardized assessments. 
  • A significant level of modifications or assistance from the therapist is required to complete the assessments. 
  • Deficits in performance may be physical, cognitive, or psychosocial. 
  • Analysis of extensive data from various sources, including the patient’s occupational profile and assessments, is used to develop several treatment options.
  • The evaluation requires a  high degree of analytical skills to complete. 

Reevaluation (OT 97168)

The occupational therapy reevaluation is not a leveled system with multiple CPT codes to choose from. Instead, it relies on a single code. Most often, you’ll conduct a reevaluation when there’s been a marked change in a patient’s present level of functioning or they’re not responding to the current therapeutic interventions. A significant, new clinical finding may also trigger a reevaluation. 

For a full explanation of OT evaluation codes and how to choose the appropriate one, read Evaluation Codes for Occupational Therapy Billing.

The 97110 CPT Code

The 97110 CPT code is one of the most frequently-used therapeutic procedure codes for occupational therapy. Knowing when to use this code, the documentation you’ll need to back it up, and when to use the 97530 CPT code instead will save you from potential billing headaches down the road.

When to Use 97110

The 97110 CPT code describes foundational therapeutic exercises designed to improve a patient’s range of motion, strength, flexibility, or physical endurance. The goal of the exercises must be to restore the ability to perform an activity of daily life or other functional activity. Exercises that fit the 97110 CPT code typically target only one deficit area. Examples include using TheraPutty to increase finger strength or a treadmill to increase endurance when walking short distances.

Required Documentation for 97110

When keeping records of your sessions with patients, focus on clearly identifying the deficit area your exercises are targeting. Connect how a lack of strength or flexibility in a specific area of the body affects their ability to function in daily life. Specify the region of the body you’re working on and how the exercises you’ve prescribed are specifically designed to remediate the deficit area and restore the loss in bodily functioning. Start with an objective measure of the client’s current level of function and update it with periodic measurements that show consistent improvement over time.

When to Use 97530 CPT Code Instead

The 97530 CPT code is a very similar billing code, but it has some important distinctions. In some cases, this code may be a more accurate descriptor of your actual work with your patient. If your work with the patient focuses on activities designed to remediate multiple deficit areas rather than simply exercises that address a single deficit area, you’ll want to consider using the 97530 CPT code instead.

Read How and When to Use the 97110 CPT Code to learn more about the difference in codes 97110 and 97530.

What to Know About ICD-10 Coding

ICD-10 is a diagnostic tool developed by the World Health Organization. ICD-10 codes are used in the United States by medical and therapy professionals to document medical and treatment diagnosis. These codes must be included in insurance claim submissions along with related CPT codes.

Common ICD-10 Coding Mistakes

ICD-10 codes are highly specific, making it easier for therapists to select codes that describe the patient’s current impairment in greater detail. But many of these codes are quite similar, increasing your chances of incorrectly coding a diagnosis. Here are a few of the most common ICD-10 coding mistakes and how to avoid them.

1. Confusing Similar Letters and Numbers 

Each ICD-10 code is three to seven characters in length and is made up of alphanumeric characters. This structure makes it easy to make careless mistakes like placing an O where a zero should be or using a 1 instead of an I. Do a double-take on your ICD-10 codes to catch any obvious errors. 

2. Omitting Laterality and Specificity

Payers require identifying laterality and coding to the highest specificity. It may be tempting to use a more generic code, but taking the time to find the one that best describes your diagnosis will reduce rejections and denials. 

3. Using an Incorrect Code

Become familiar with the ICD-10 codes used most often with occupational therapy patients. Knowing the codes can help ensure you’re choosing the one that offers the most accurate portrayal of the patient’s presenting problem.

4. Incomplete Documentation

ICD-10 codes require documentation to back them up. Keeping detailed notes of your therapy sessions, recording data from objective assessments of a patient’s current functioning levels, and including specific details like site-specificity can help you justify your choice of a diagnosis code if it’s ever challenged. 

Tips for Choosing the Best OT ICD-10 Code

While it can sometimes be challenging to know which code is the best one for a patient, these three tips should help you. 

  • Support Your Coding Choice with Documentation — The notes that you keep from your sessions should support your ICD-10 coding choice. Objective measures of the patient’s impairment and short and long term goals from their plan of care should directly support the ICD-10 codes you’re using. Detailed information like dominant side, site-specificity, and the affected body part is valuable information to have handy in the event of a claims denial or audit.
  • Be Sure Treatment is Medically Necessary for the Diagnosis — The code you choose must be medically necessary and directly relate to the service you provided to the patient.
  • Avoid Unspecified Codes When Possible — Unspecified codes have their place in ICD-10 coding. There are certain instances where using one may be your only option. But because unspecified codes tend to be used as shortcuts, you’ll want to be sure you use them only if a specified code isn’t available.

For more on ICD-10 coding, read Top ICD 10 Codes for Occupational Therapy.

OT Practice Management Software Can Help Make Billing Easier

There are a lot of moving parts to occupational therapy billing. Using a good practice management software can help you prevent mistakes and streamline your process, speeding up reimbursements. Practice management software allows you to store information digitally and auto-populate your claims forms with details from your notes. It can also help ensure you’re using the best codes for your services. 

See how Fusion’s practice management system can help you improve your claims acceptance rate, and request a free demo today!

Goals inspire us and give us milestones to work toward. Writing effective pediatric occupational therapy goals is especially important for the success of your patients and your practice. Goals establish a structure for planning and tracking progress while providing ongoing motivation for both you and your patients. Having a set of established goals for each patient allows other professionals to work productively with your patient when you are out. And they speed up the reimbursement process by reducing the chance of your claim being rejected. Perhaps most importantly, effectively-written goals have been proven to improve patient outcomes. In this post, we’ll look at three formats for goal-writing and offer effective examples of pediatric occupational therapy goals.
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