Billing CPT code 97014

Payment for OT is limited to the treatment of disease for individuals whose ability to function in life roles is impaired. OT can be provided by a physician or occupational therapist and may include physical agents such as massage, electricity, traction, or exercises as forms of therapy. Examples of what may be considered acute are as follows:

OT is considered acute for 180 calendar days from the first date (onset) of therapy for a specific condition. Providers may file an appeal for claims denied as being beyond the 180 days of therapy with supporting documentation that the client’s condition has not become chronic and the client has not reached the point of plateauing. 

A client may receive therapy in more than one distinct therapy type on the same date of service when the therapy is rendered at different times. 

An evaluation or reevaluation performed on the same date of service as a therapy from a different therapy type must be performed at distinctly separate times to be considered for reimbursement.

Claims for OT services must include modifier GO to be considered for reimbursement. Modifier AT must also be submitted with all claims for therapy procedure codes for acute conditions or the claims will be denied. Modifiers are not required for evaluations or reevaluations. 

Reimbursement for OT procedure codes is based on the actual amount of billable time associated with the service. Services for which the unit of service is 15 minutes (1 unit = 15 minutes) should be rounded up or down to the nearest quarter hour. To calculate billing units, count the total number of billable minutes for the calendar day for the client, and divide by 15 to convert to billable units of service. If the total billable minutes are not divisible by 15, the minutes are converted to one unit of service if they are greater than seven and converted to 0 units of service if they are seven or fewer minutes. 

For example, 68 total billable minutes/15 = 4 units + 8 minutes. Since the 8 minutes are more than 7 minutes, those 8 minutes are converted to one unit. Therefore, 68 total billable minutes = 5 units of service. 

Time intervals for 1 through 8 units are identified in the following table:

The following procedure codes may be reimbursed in 15-minute increments for a combined maximum of eight units (two hours) per day, per therapy type:

Occupational 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. When billing for occupational group therapy, procedure code 97150 must be used for each member of the group. Procedure code 97150 will be denied when billed on the same date of service by the same provider as procedure code 97750.

Procedure codes 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, and 97150 are limited to one per day, per therapy type.

Procedure codes 97535, 97537, and 97542 are only payable for clients birth through 20 years of age in an outpatient rehabilitation setting or through CCP.

Evaluation procedure code 97003 is payable once per 180 days, any provider. Reevaluation procedure code 97004 is payable once per 30 days, any provider. 

OT evaluations or reevaluations (procedure code 97003 or 97004) will be denied when any of the procedure codes in the following table are billed with modifier GO by any provider on the same date of service: