The following describes the framework for AOTA's proposed changes to the Common Procedural Terminology (CPT) coding structure and how codes would be reported on a claim form. The total number of codes to be used for occupational therapy has been reduced by approximately half, a goal that has been referenced by several policy makers.
Evaluation, Assessment, and Review Section (E&R)
Coding for each and every visit will include a code for evaluation, assessment, and review to reflect that these elements are always part of the clinical reasoning in any session.
- The occupational therapy evaluation code has been expanded into 3 levels of evaluation. The definitions and descriptive information determine the level, whether of low, moderate, or high work intensity that would be reported by an occupational therapist. Differences in levels are based on the complexity of the evaluation, considering client condition, comorbidities, performance strengths and weaknesses, and therapist's clinical decision-making.
- The occupational therapy re-evaluation code has been reworded, with clarifying information.
- A new code has been added to describe a simple review of patient status that would be done at the start of each regular treatment session, assuming no other evaluation or assessment is needed or billed on the same day.
- The wheelchair management and assistive technology assessment codes have been changed to reflect the total service provided in a session (i.e., 15-minute unit designations have been deleted). These can be billed as stand-alone codes or with other interventions, but they cannot be billed with other E&R codes.
Intervention Codes Section
Interventions performed in a visit can be billed in addition to the above referenced E&R code. The E&R codes that reflect an evaluation can be billed alone. However, the review code cannot be billed alone but must be billed with add-on code(s), meaning that a review of patient status alone would not be considered a billable session.
A practitioner can do an evaluation or review and then move into treatment, coding both an E&R code and add on code(s) in one session, or simply do an evaluation. One or more add-on codes may be billed for a single session, as appropriate, to reflect what is done in the session. Or, an evaluation code (except for the review of patient status) can be billed as the only service provided in a session.
The way the codes are constructed, they should also convey information on the objectives of the session.
Intervention codes have been changed to reflect the total service provided in a visit or session and are no longer time dependent. (i.e., 15-minute unit designations have been deleted).
- There are new codes that describe services using the International Classification of Functioning, Disability, and Health (ICF) terminology (e.g., body structures and functions, sensation and sensory processing, mental functions, cognitive functions, ADLs, IADLs). They encompass many of the services described by the existing CPT procedure codes but with a new clarity and directness about the intervention because of the ICF terminology.
- Physical agent modalities have been grouped into categories to streamline the use of these codes.
- Some slight revisions have been made to the manual therapy, physical performance testing, and orthotics fitting and training codes to enable their use as add-on codes. These will reflect total service—untimed instead of per 15-minute units.
- A separate occupational therapy group code is still under discussion.
- The work hardening and wound care codes are still under discussion.