Occupational Therapy CPT Codes: 97165 to 97168, 97110, 97530, 97535

AOTA's summary of the CPT descriptors lists three required components for every OT evaluation: an occupational profile with medical and therapy history, an assessment of performance deficits, and clinical decision making. The level is set by the depth of the history (brief, expanded, extensive), the number of performance deficits identified (1 to 3, 3 to 5, 5 or more), and the complexity of decision making, including comorbidities and whether tasks had to be modified for the client to complete the evaluation. AOTA notes that each component in the descriptor must be documented to report the chosen level.

Re-evaluation (97168) is not routine. The Medicare billing article says indications include new clinical findings, a significant change in condition, or failure to respond to the interventions in the plan of care, and that re-evaluations are not billed just to update a plan of care, recertify, or write a progress report.

Pick the code by the purpose of the activity, not the equipment. The Medicare article says exercise taught and performed to restore strength, range of motion, endurance or flexibility is 97110. Therapeutic activities (97530) use dynamic functional activities to improve performance. Self-care and home management training (97535) covers ADL and compensatory training, safety procedures, and instruction in adaptive equipment for use at home.

The same article warns that 97535 should not be used for every home instruction. Teaching a home exercise program for strength is 97110; teaching the client to use a sock aid for dressing is 97535.

Medicare counts timed units from the total timed minutes for one discipline on one date. Noridian states that a timed code needs at least 8 minutes of direct treatment to be billed, and the Medicare billing article gives the chart below. Untimed evaluation minutes are not added to the timed total.

The article's example: 20 minutes of 97110 plus 20 minutes of 97535 gives 40 timed minutes, which supports 3 units. Units are then assigned to codes by their 15 minute blocks and remaining minutes. The article also tells therapists to record actual minutes as "Timed Code Treatment Minutes" and "Total Treatment Time", not time in and time out or units.

• GO: services delivered under an outpatient occupational therapy plan of care. Noridian says it goes in the first or second modifier position when other modifiers are needed.
• CO: OT services furnished in whole or in part by an occupational therapy assistant. CMS pays these at 85 percent of the otherwise applicable fee schedule amount.
• KX: added when a client's therapy goes over the annual Medicare KX threshold amount. CMS says claims over the threshold without KX are denied.
• 95: CMS names modifier 95 for outpatient therapy by telehealth from OTs employed by hospitals. See the telehealth modifiers guide.