Although occupational therapists are unable to provide your child with a medical diagnosis, they do utilize a “treatment diagnosis” code during documentation and billing, to support reasoning behind interventions utilized within the practice. A patient’s documented treatment diagnosis, known as an ICD-10 code, must correctly correspond to the condition in which a patient has and the intervention that is being given in order for an insurance company to properly pay the provider. A medical diagnosis and a treatment diagnosis may sometimes be the same, but many times a more specific ICD-10 treatment diagnosis code may need to be given in order to best reflect the conditions in which a professional is providing services for. Some common ICD-10 codes used within the pediatric setting are as followed (but in no way are limited to):
G98.8 – Other Disorders of the Nervous System
R27.8 – Other Lack of Coordination
F82.0 – Specific Developmental Disorder of Motor Function
F80.2 – Mixed Receptive-Expressive Language Disorder
M62.81 – Generalized Weakness
F84.0 – Autism
F90.0 – Attention Deficit Hyperactivity Disorder
Current Procedural Terminology, commonly referred to as a CPT code, is a numerical code that is universally used by healthcare professionals in order to allow insurance companies the ability determine the appropriate amount of money that needs to be paid for a specific service provided for a client.
CPT codes are often used for evaluations. The CPT code used for your child’s evaluation depends on the complexity of the process. The following chart breaks down the different CPT codes that may be used to document an evaluation given:
The interventions utilized within this practice are endless, which is why your occupational therapist will focus on the therapeutic goals specific to your child when selecting the standardized five-digit code to send to your insurance company. It is important to note that not all codes are accepted by all payers. There are specific state regulations and payer policies that need to be taken into consideration before an occupational therapist submits a claim.
Treatments are most commonly billed in 15-minute units. The CPT code used is congruent to the individual’s goals developed through family consultation with the occupational therapist upon evaluation. Common CPT codes used within the pediatric setting are as followed (but in no way are limited to):
97110 – therapeutic exercises to develop strength and endurance, range of motion and flexibility
97129 – Therapeutic interventions that focus on cognitive function (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; initial 15-minutes
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; each additional 15 minutes (List separately in addition to code for primary procedure)
97533 – Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes
97124 – Massage including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
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.
Modifiers are added to CPT codes to specify a procedure more accurately. The 59 modifier is most commonly used to indicate that two or more services were performed on the same day, although not normally reported together. The 59 modifier is only used when the two treatments are completed during different 15-minute intervals. When a modifier 59 is added to a CPT code, a provider is able to receive separate payment for each service provided.
Coverage for services also depends on the form of care being given; whether your child is receiving restorative care or developmental care will impact an insurances decision to offer coverage. Every insurance company is different, but many companies do not offer coverage for developmental delays. When a child does not reach specific milestones by an expected time period, this indicated a developmental delay. Occupational therapists work with children who are experiencing these delays, as well as their families, to improve motor, cognitive, sensory, and play skills.
Instead of offering coverage for developmental delays, many insurance companies will instead offer coverage for restorative care. Restorative care focuses on assisting a client towards returning to their previous level of functioning, such as utilizing interventions and tools to improve fine motor skills, sensory processing skills, cognitive skills, social integration skills, and tools to aid in activities of daily living.
It can be scary to consider the impact that insurances can have on the availability of care for your child. It can also be hard on parents to go through the process of getting a diagnosis, knowing that your coverage might be hindered by your company’s policies on developmental diagnoses. Working directly with your insurance provider to understand the ins and outs of your plan is the best plan of action. Before beginning services, it is important that you asked yourself some of the following questions:
- How many sessions are allowed under my insurance plan?
- Are there any exclusions to coverage, such as an evaluation being covered but not sequential treatment plans?
- Will I need a new physician referral at some point?
- In my coverage limited to specific settings?
An insurance claim may be denied because of one or several reasonings. Some of which include an incomplete form (such as missing coding information), the therapy is not covered under your plan, or coverage limitations (such as having maxed out on the number of visits). In case something like this were to arise, it is important that you keep detailed records of any conversations held between yourself and your insurance company, the dates and treatment outcomes from your child’s sessions, and any recommendations made from the provider. A denial can be appealed, in which you would incorporate the reasoning behind your appeal letter, your child’s medical history, and any recommendations from therapists, specialists, or pediatricians.
What is a ICD-10? A system used by all healthcare providers to classify and code all diagnoses and symptoms.
What is a CPT code? A five-digit code that indicates to health insurance companies, the type of service performed to your child.
Will my child’s diagnosis effect my coverage? Every insurance company is different. Check with your provider about the coverage offered and the policies within your plan. Coverage also varies across states in terms of covering different diagnoses.