Pediatric occupational therapy with autistic children: A guide to coding and billing for play and social participation

A message about language: We use identity-first language in alignment with the autistic community’s preference (Chapman, 2021; Kenny et al., 2016; Taboas et al., 2022).

Occupational therapy practitioners (OTPs) are uniquely positioned to incorporate the caregiver(s) into each autistic child’s occupational therapy (OT) treatment plan, however, relationship-focused interventions with autistic children in the areas of play and social participation can be challenging to document, code, and bill, making reimbursement more complex than for interventions targeting a less subjective skill, such as cutting with scissors or buttoning buttons, for a variety of reasons.

1. Relationship-focused goals targeting skills such as engagement, back-and-forth interactions, and shared enjoyment can be subjective and difficult to quantify or measure progress.
2. They are habilitative in nature as opposed to rehabilitative. Despite the inclusion of rehabilitative services as an essential health benefit, challenges still exist with reimbursement, as health insurance views these benefits differently than rehabilitative benefits. For example, payers may have different visit limits for rehabilitative and habilitative services (Barrington et al., 2022). Furthermore, identifying covered habilitative services can be challenging when selecting a health insurance plan, as only 50% of plans list therapies under this category (American Occupational Therapy Association [AOTA], 2019).
3. Autistic individuals demonstrate fluctuating capacities. An autistic child may be able to participate in an activity or complete a task one day and not the next (den Houting, 2018). Goal achievement is a commonly selected metric by payers to support the benefit of OT intervention. Fluctuating capacities can make it challenging to meet a goal confidently.

This document serves as a resource for successful documentation, coding, billing, and, ultimately, reimbursement for relationship-focused pediatric occupational therapy sessions with autistic clients and their caregivers.

Within the guide, topics addressed include:

• Background on types of play and social participation
• OT models and frameworks applicable to play and social participation
• Diagnosis coding appropriate to the client population
• Current procedural terminology (CPT) codes that capture play, social participation, and caregiver training with example case studies
• Documenting to support payment
• Preventing denials
• Supporting payment advocacy
• Links to AOTA and external resources