Billing, Coding and Insurance

How are pediatric occupational therapy services paid for?

There are multiple ways parents can pay for their child’s occupational therapy.

Medicaid:
- Medicaid is a federal and state health insurance program that provides health coverage to individuals and families with a limited income.
- Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit covers “medically necessary” services, including occupational therapy, for children under 21 years old.
Children’s Health Insurance Program (CHIP):
- CHIP is a federal and state health insurance program that provides health coverage to children from families with low income but whose income is higher than the cutoff to receive Medicaid.
Private Insurance:
- Parents may receive private insurance from their job or pay for private insurance.
- Your insurance plan may be in-network or out-of-network for certain occupational therapy providers.
- Call your health insurance company to find in-network providers, ask which diagnoses/conditions are covered, and inquire about whether you will be charged a copay or coinsurance for occupational therapy visits.
Federal Funding (Early Intervention):

- Under the Individuals with Disabilities Education Act (IDEA) Part C, infants and toddlers with disabilities and their families are eligible for early intervention (EI) services.
- EI services are partially funded by a federal grant and the rest of payment may be covered by health insurance or charged for on a sliding scale.

Private payment:
- If occupational therapy services are not covered for your child through your health insurance plan, you may pay for services out-of-pocket.
- OT services may be charged for on a sliding scale.
Medicare:
- Medicare is a federal and state health insurance program that mainly provides health coverage to individuals age 65 and older as well as adults with specific diagnoses who receive Social Security disability benefits.
- Medicare also covers children under age 18 who are diagnosed with end stage renal disease as well as individuals between the ages of 20 and 22 who receive Social Security disability benefits.

What are ICD-10 codes?

ICD-10 stands for International Classification of Diseases (Tenth Revision)
ICD-10 codes are numerical codes defined by the World Health Organization to identify medical diagnoses.
These codes are used by healthcare providers to justify billing for provided services.

Common ICD-10 Codes in Occupational Therapy:

F82.0: Dyspraxia
F84.0: Autism
F90.0: Attention Deficit Hyperactivity Disorder
G98.8: Other Disorders of the Nervous System
M62.81: Generalized Weakness
R13.11: Dysphagia, Oral Phase
R27.8: Other Lack of Coordination
R63.3: Feeding Difficulties
Q90.0: Down Syndrome

What are CPT codes?

CPT stands for current procedural terminology
CPT codes are numerical codes defined by the American Medical Association to identify procedures and services performed by healthcare providers including occupational therapists.
CPT codes can be used to describe various types of evaluation, therapeutic procedures, and modalities procedures.
Procedures are typically billed for in 15-minute interval units.

Common CPT Codes Used by Occupational Therapists:

Evaluation Codes:

97165: Low complexity occupational therapy evaluation
97166: Moderate complexity occupational therapy evaluation
97167: High complexity occupational therapy evaluation
97168: Occupational therapy reevaluation

Therapeutic Procedures:

97110: Therapeutic procedure using exercise to develop strength, endurance, range of motion and flexibility, each 15 minutes.
97112: Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.
97124: Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
97129: Therapeutic interventions that focus on cognitive function (e.g. attention, memory, reasoning, executive function, problem solving and/or pragmatic function) and compensatory strategies to manage the performance of an activity (e.g. managing time or schedules, initiating, organizing and sequencing tasks.). Billed for the initial 15 minutes of treatment provided
97130: Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact. Billed for each additional 15 minutes of treatment provided
97150: Group therapeutic procedures (2 or more clients)
97533: Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes
97535: Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes

Modalities Procedures:

97010: Application of hot/cold packs to one or more areas
97014: Application of electrical stimulation to one or more areas (unattended by therapist)
97024: Application of heat therapy to one or more areas
97032: Application of modality to one or more areas; electrical stimulation (manual), 15 minutes
97035: Ultrasound, 15 minutes

What are modifiers?

Modifiers are two-digit (letters, numbers, or a letter & number) codes added to CPT codes to add more information about the procedure provided by the occupational therapist or other healthcare provider.
Modifiers are not always required but may be required to describe certain billing situations.
Modifier 59 is one modifier that can be applied to CPT codes describing occupational therapy services. Modifier 59 describes when two services (each 15-minutes) that are usually billed together are billed separately due to being performed as two different interventions.