Therapy rules with an occupational focus
Occupational therapy is a rehabilitation discipline that helps patients regain the skills of daily living and work — after injury, surgery or stroke, for hand and upper-limb conditions, and for children with developmental needs. Its billing follows the same broad therapy rules as physical therapy, with its own evaluation codes, modifiers and Medicare threshold, plus custom orthotics and splints that many OT practices fabricate.
Evaluations and treatment codes
| Type | Examples | Billed |
|---|---|---|
| Evaluations | 97165, 97166, 97167 (low, moderate, high complexity); 97168 re-evaluation | Once per encounter |
| Timed treatment | 97530 therapeutic activities, 97535 self-care and home management training, 97110 therapeutic exercise, 97140 manual therapy, 97112 neuromuscular re-education | In 15-minute units |
| Orthotics | 97760 orthotic management and training; 97763 subsequent encounters; custom devices with L-codes | Per unit or per device |
Timed units follow the Medicare 8-minute rule for Medicare and payers that use it, or the per-code rule some commercial plans apply. Code pairs that NCCI bundles — such as 97530 and 97140 — need separate, documented time intervals and a 59 or X modifier.
Medicare modifiers and the OT threshold
- GO on every outpatient occupational therapy line.
- KX once the patient’s yearly OT spending passes the Medicare threshold. Occupational therapy has its own threshold, separate from the combined physical therapy and speech-language pathology threshold.
- CO on services furnished in whole or in part by an occupational therapy assistant above the de minimis share, which Medicare pays at a reduced rate.
- A plan of care certified by a physician or qualified practitioner, recertified at least every 90 days, and progress reports at least every 10 treatment days.
Hand therapy, pediatrics and other payers
Hand therapy practices fabricate custom orthoses, billed with the HCPCS L-code for the device in addition to the fitting and training time, and need clear documentation of custom fabrication. Pediatric OT is often covered through Medicaid and EPSDT, with authorization for each episode, and some commercial plans limit visits or exclude developmental therapy. Workers’ compensation claims follow state fee schedules. Each therapist must be credentialed with each payer.