Many of the inquiries I receive are about coding and the proper use of coding in billing. In the next two columns I will address some of the most commonly asked questions about coding for occupational therapy services in the private practice setting.
1. What is the difference between ICD codes and CPT codes?
ICD stands for the International Classification of Diseases. The ICD series of codes was established approximately 400 years ago by European physicians. It currently belongs to the World Health Organization and is used today to group and classify diseases. On a worldwide basis, the diagnostic classification of diseases provides a basis for tracking and monitoring outbreaks, progressions and regressions of disease processes in various regions. In terms of billing, these codes serve to provide the reason and the medical necessity for the service that the patient is receiving.
CPT stands for Current Procedural Terminology Codes. CPT codes are copyrighted and owned by the American Medical Association. These codes, developed by the Health Care Financing Administration (now the Centers for Medicine and Medicaid Services), were established in the mid-1960s, with the first CPT manual published in 1983. They were established as a first step toward standardizing health care terminology and providing a means of objectively tracking services rendered. Another purpose is to assist in the assignment of reimbursement amounts to providers by Medicare.
These codes describe medical or psychiatric procedures performed by physicians and other health care providers, including occupational therapists. Every year a new CPT book comes out because codes for new procedures are added (highlighted by red bullets). At this point most managed care and private insurance companies base their reimbursements on the CPT values established by CMS. For OT it is important to note that some CPT codes are time-based and others are modality based. ICD and CPT codes together are considered HCPCS; this acronym means: H - Health care C - Common P - Procedural C - Coding S - System.
2. What common CPT codes do OTs use?
The codes most often used for billing occupational therapy are listed below. Please note that the AMA defines a therapeutic procedure as a manner of effecting change through the application of clinical skills and/or services that attempt to improve function. During a therapeutic procedure the therapist is required to have direct (one on one) patient contact.
97110 - Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97112 - Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture and/or proprioception for sitting and/or standing activities
97113 - Aquatic therapy with therapeutic exercises
97124 - Massage, including effleurage, petrissage and/or tapoment (stroking, compression, percussion); (for Myofacial Release, use 97140)
97139 - Unlisted therapeutic procedure (specify)
97140 - Manual therapy techniques (e.g. mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
97150 - Therapeutic procedure(s), group (2 or more individuals) (report 97150 for each member of group); (group therapy procedures involve constant attendance of the physician or therapist, but by definition do not require one-on-one patient contact by the physician or therapist)
97504 - Orthotic(s) fitting and training, upper extremity(ies), lower extremity(ies), and/or trunk, each 15 minutes
97520 - Prosthetics training, upper- and/or lower-extremity training, each 15 minutes
97530 - Therapeutic activities, direct one-on-one patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
97532 - Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct one-on-one patient contact by the provider, each 15 minutes
97533 - Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct one-on-one patient contact by the provider, each 15 minutes
97535 - Self-care home management training (e.g. activities of daily living and compensatory training, meal preparation, safety procedures, and instruction in use of assistive technology devices/adaptive equipment), direct one-on-one contact by the provider, each 15 minutes
97537 - Community/work reintegration training (e.g. shopping, transportation, money management, avocational activities and/or work environment/modification analysis), direct one-on-one patient contact by the provider, each 15 minutes
97542 - Wheelchair management/propulsion training, each 15 minutes
97545 - Work hardening/conditioning, initial 2 hours
3. Does an OT have to spend a full 15 minutes with a patient doing direct one-on-one contact in order to bill for each CPT code?
As you can see from the list above, only certain CPT codes are driven by time. For those that are, it is understood that "pre-and post-service" time is built into the 15-minute time increment. This includes sub components of the procedure such as preparing or positioning the patient, as well as explaining the procedure to the patient. All of this is considered part of the 15 minutes of direct patient contact required when using the time-driven codes.
More questions answered in the next column, Oct. 3.
Iris Kimberg, MS, PT, OTR, has worked in the non-clinical aspect of therapy for the past 27 years. She has recently launched New York Therapy Guide, a site dedicated to the growth, viability and success of therapists in the private sector. Iris enjoys sharing her expertise with others in the field through workshops, seminars and private consultations. She can be reached at firstname.lastname@example.org.