Simplify Processes, Maximize Reimbursements, Empower Care InOccupational Therapy (OT) is a form of therapy for those recovering from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life. Some of these activities include promoting health and wellness, preventing or living better with illness, injury, or disability, increasing independent function, enhances development and adaptation of task or environments to achieve maximum independence.
Accurate billing is the backbone of successful occupational therapy practices. Improved processes not only protect your financial health but also let you focus on transforming lives.
This article will explore 2025 provider changes in private practice, an integral part of the non-clinical side of Occupational Therapy, along with Billing and Coding. Partner with Neolytix to explore a new level of precision, efficiency, and expertise in billing excellence.
Table of Contents
What Is Included in an Occupational Therapy Evaluation?
Occupational therapy evaluations are the cornerstone of effective care, offering a tailored roadmap to restore patients’ independence and well-being. These assessments go beyond numbers, focusing on the human experience:
Human-Centric Process
Every patient brings unique challenges and goals. Evaluations prioritize understanding their physical, cognitive, and psychosocial needs to craft a comprehensive profile. From overcoming mobility issues to improving daily routines, these elements build the foundation for therapy success.
A typical occupational therapy evaluation includes the following components: Occupational profile
The history of the patient involving their occupational history is one of the major components that is considered during the Occupational therapy evaluation. Also, his interests, values, needs and patterns of daily living are taken into consideration to a great extent.
Patient history
The medical and therapeutic history of the patient is also a significant component for the evaluation of occupational therapy.
Clinical decision making
Plan Development
This component of the occupational therapy evaluation involves formulating a customized plan for the care of the patient and ensuring that the goals are met accurately.
The level of occupational therapy evaluation performed is determined by the patient’s condition, complexity of clinical decision, and the scope and nature of the patient’s performance deficits relating to physical, cognitive, or psychosocial skills to be assessed.
- Physical skills: Refers to the impairment of body structure or body function.
- Cognitive skills: Refers to ability to attend, perceive, think, understand, problem solve, mental sequence and remember resulting in the ability to organize occupational tasks.
- Psychosocial skills: Refers to interpersonal interactions, habits, routines and behaviors which are required to actively participate in daily activities
Diagnosis
Diagnosis codes for OT’s service typically apply to adults and children. Medical billers and coders will want to watch for diagnosis codes, some may have an age range. The type of conditions patients are motor skills issues, weakness, incoordination and falls in both adults and children.
For instance, ICD-10-CM codes for feeding are defined as feeding difficulties and pediatric feeding disorders acute or chronic.
- R63.30 Feeding difficulties, unspecified
- R63.31 Pediatric feeding disorder, acute
- R63.32 Pediatric feeding disorder, chronic
- R63.39 Feeding difficulties, other
Additional diagnosis used for billing for OT services are:
- Developmental Delays
- Sensory
- Common codes: stiffness, brachial plexus disorders, paraplegia and ataxia.
2025 Occupational Therapy Changes
In 2025 there is a substantial change for occupational therapists in private practice. Beginning, January 1, 2025, Centers for Medicaid and Medicare (CMS) will implement a rule allowing general supervision of occupational therapy assistants (OTAs) by occupational therapists in private practice for all applicable occupational therapy (OT) services. This means OTs in private practice can now generally supervise OTAs under their license; this aligns with the same policy for physical therapists and physical therapist assistants in private practice.
This change could potentially increase access to OT services, especially in rural areas and pediatric practices, by allowing OTPPs to utilize OTAs more readily. This change allows for “general supervision” of OTAs by OTPPs, which means the OT does not need to be physically present for all OTA services. This change follows the general supervision policy for PTAs and OTAs by PTs and OTs who work in institutional providers and gives more flexibility to PTPPs and OTPPs in:
- Meeting the needs of patients
- Safeguarding patients access to medically necessary therapy services, especially in rural and underserved areas
Key CPT Codes for Occupational Therapy Evaluations and Procedures
CPT codes serve as the universal language between providers and payers, capturing the scope and complexity of services rendered. For 2025, updates ensure better clarity and alignment with therapy goals.
There are three codes to describe increasing evaluation complexity: low, moderate, or high. At a minimum, each of the components noted in the code descriptor must be documented, in order to report the selected level of occupational therapy evaluation.
Sources: AOTA; AOTA New Occupational Therapy Evaluation Coding Overview.
Most Common CPT codes for Therapeutic and Modalities Procedures
The following list contains the most used therapeutic procedures codes and modalities procedure codes that would be rendered by an occupational therapist. Please note the importance of time in certain codes.
| CPT Code | Description |
|---|---|
| 97165 | 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 (ie, 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 (eg, 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 |
| Occupational therapy evaluation, moderate complexity, requiring these components: | |
| 97166 | ■ 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 (ie, 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. Patients may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, 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 |
| 96167 | 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 identifies 5 or more 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 high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patients present with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, 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 |
| 96168 | Re-evaluation 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 |
Therapeutic Procedures Codes
Beyond evaluations, occupational therapists rely on codes for therapeutic exercises, sensory integration, and advanced modalities like ultrasound. Neolytix’s user-friendly table simplifies referencing these key codes, ensuring therapists stay compliant while focusing on patient care.
Modalities Procedure Codes
| CPT Code | Description |
|---|---|
| 97110 | Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility |
| 97112 | Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities |
| 97113 | Aquatic therapy with therapeutic exercises |
| 97116 | Gait training (includes stair climbing) |
| 97124 | Massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) (Note: For myofascial release, use 97140) |
| 97129 | 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; initial 15 minutes |
| add on code 97130 | Each additional 15 minutes (List separately in addition to code for primary procedure.) |
| 97139 | Unlisted therapeutic procedure (specify) |
| 97140 | Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes |
| 97150 | Therapeutic procedure(s), group (2 or more) (Report for each member of the group) (Group therapy procedures involve constant attendance by the physician or other qualified health care professional [i.e., therapist], but by definition do not require one-on-one patient contact by the same physician or other health care professional.) |
| 97530 | Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes |
| 97533 | Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes |
| 97545 | Work hardening/conditioning, initial 2 hours |
| 97546 | Add-on code for each additional hour of work hardening or conditioning after the initial two hours |
Supervised The application of a modality that does not require direct (one-on-one) patient contact.
Modalities are used to alleviate pain, improve circulation, reduce swelling, reduce muscle spasm, and deliver medications in conjunction with other procedures.
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CMS 8 Minute Rule
Ever heard about CMS 8-Minute rule? A recent statement has been released by CMS which states the following–
When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes. For any single timed CPT code in the same day measured in 15-minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes. If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes through and including 37 minutes, then 2 units should be billed.
| CPT Code | Description |
|---|---|
| 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 1 or more areas |
| 97033 | Application of medication through skin using electrical current, 15 minutes each |
| 97016 | Application of a modality to one or more areas; vasopneumatic devices |
| 97018 | Paraffin bath |
| 97022 | Whirlpool |
| 97032 | Application of modality to one or more areas; electrical stimulation (manual), 15 minutes each |
| 97033 | Iontophoresis, 15 minutes each |
| 97034 | Contrast baths, 15 minutes each |
| 97035 | Ultrasound, 15 minutes each |
Source: CMS Manual System. The following chart outlines the time units to be reported based on the times specified in the medical documentation. For all CPT codes designated as 15 minutes, multiple coding represents the minimum face-to-face treatment for the specific CPT code reported:
For example, suppose an occupational therapist states that therapeutic exercises were performed on three different areas to develop strength and endurance for 38 minutes. The therapist would report three units for the procedure.
Multiple Procedures with Designation of Time
When an occupational therapist performs multiple procedures during the same encounter, the units to be reported are based on the total time of all the procedures. Suppose during one session, a provider performed 39 minutes of therapeutic exercise (normally 3 units) and 23 minutes of massage exercise (normally 2 units). In this case, it would be incorrect to bill 3 units of therapeutic exercise and 2 units of massage exercise for this session. This is due to the following CMS rule:
If more than one 15-minute timed CPT code is billed during a single calendar day, then the total number of timed units that can be billed is constrained by the total treatment minutes for that day.
Since the total time of all procedures is 39 + 23 = 62 minutes, and 62 minutes is reported as 4 units, the total billed units for the session cannot exceed 4.
Units | Number of Minutes |
1 unit | 8 minutes to < 23 minutes |
2 units | 23 minutes to < 38 minutes |
3 units | 38 minutes to < 53 minutes |
4 units | 53 minutes to < 68 minutes |
5 units | 68 minutes to < 83 minutes |
6 units | 83 minutes to < 98 minutes |
7 units | 98 minutes to < 112 minutes |
8 units | 113 minutes to < 127 minutes |
The pattern remains the same for treatment times more than 2 hours | |
The procedure performed for the longest amount of time should have the higher number of units. In this example, the provider reduces the units of the shorter procedure (massage exercise) from 2 to 1. This allows the total billable units to not exceed 4.
Hence, the correct way to bill these two procedures is 3 units of the therapeutic exercise and 1 unit of massage exercise.
Occupational Therapy Documentation Essentials: The SOAP Method
Clear, concise, and consistent documentation is the backbone of successful occupational therapy billing. The SOAP (Subjective, Objective, Assessment, Plan) method remains the gold standard for organizing patient records and justifying billed services. To have a perfect SOAP format, here are a few things that a therapist must keep in mind:
Breaking Down SOAP:
Subjective: Capture the client’s reported experiences, such as pain levels, progress, or challenges, in their own words.
What is the client reporting?
What are the client’s parents or caregivers reporting?
Is the client reporting pain?
Are they complaining of fatigue?
Objective: Record measurable observations, such as patient performance, assistance levels, and success rates.
What level of assistance did the client need?
How many verbal and physical prompts were provided?
What did you observe?
How did you grade the activity or modify the environment?
In what percentage of trials was the client successful?
What progress is the client currently making on their goals?
Assessment: Analyze data to evaluate progress and justify interventions. Highlight improvements or changes in functioning.
After examining the subjective and objective data, what does this mean about your client’s progress?
Why did you select a certain intervention activity?
Have there been any significant changes in functioning?
Plan: Detail next steps, adjustments to care plans, and any referrals.
Should the treatment plan be changed? How?
Does a new referral need to be made?
Are any accommodations or modifications recommended?
Solid documentation not only supports claims but also enhances patient care.
Occupational Therapy Medical Billing and Coding Modifiers
Modifiers indicate that a performed service or procedure has been altered by some circumstance but not changed in its definition or occupational therapy medical billing code. To receive proper payments for services rendered, the following modifiers are used when reporting occupational therapy procedures:
Modifier GO: services delivered under an outpatient occupational therapy plan of care. Medicare administrative contractors will return or reject claims containing an “always therapy” procedure code and do not also contain the correct discipline-specific therapy modifier.
Modifier GP: services that are delivered under an outpatient physical therapy plan of care.
Modifier KX: used to verify that services are medically necessary as justified by the appropriate documentation in the medical record once the threshold amount has been attained. Important! If a claim is submitted with KX modifier and the cap is exceeded, those services will be denied.
Modifier CO: specifies that services rendered were performed by an occupational therapy assistant under a therapy plan of care.
Most Common Reasons for Occupational Therapy Claim Denials
- Incorrect Modifiers
- Audits for Overuse
- Incorrect calculation of Time-Based Codes
Your Billing Ally in an Evolving Healthcare Landscape
Proper billing and coding practices are essential for every occupational therapy practice. At Neolytix, we aim to provide helpful insights on properly using occupational therapy CPT codes to ensure they do their best to optimize their billing processes to maximize reimbursements.
Tailored Services:
From coding audits to revenue cycle management, Neolytix offers solutions designed to fit the unique needs of occupational therapists.
Our expertise ensures compliance with the latest 2025 coding updates, leaving no room for costly errors.
Powerful Tools:
Neolytix has been helping occupational therapist organizations nationwide improve their financial health for almost 12 years. Schedule a demo with us and let us show you how our coding audit service, medical billing and coding services or comprehensive revenue cycle management services can benefit your organization.
