| Program Name: | BadgerCare Plus and Medicaid | Handbook Area: | Therapies: Physical, Occupational, and Speech and Language Pathology | | 04/23/2024 | Covered and Noncovered Services : CodesTopic #2793 Occupational Therapy Procedure Codes
Covered OT services are identified by the allowable CPT and HCPCS procedures codes listed in the following table.
Note: Procedure codes for many OT services are defined as
15 minutes. One unit of these codes = 15 minutes. If less than 15 minutes is
used, bill in decimals. For example, 7.5 minutes = .5 units. All other
procedure codes for OT services do not have a time increment indicated in
their description. For these procedure codes, a quantity of "1" indicates a
complete service.
| General Casting |
| Procedure Code |
Description |
| 29065 |
Application, cast; shoulder to hand (long arm) |
| 29075 |
elbow to finger (short arm) |
| 29085 |
hand and lower forearm (gauntlet) |
| 29086 |
finger (eg, contracture) |
| 29345 |
Application of long leg cast (thighs to toes) |
| 29355 |
walker or ambulatory type |
| 29365 |
Application of cylinder cast (thigh to ankle) |
| 29405 |
Application of short leg cast (below knee to toes); |
| 29425 |
walker or ambulatory type |
| 29445 |
Application of rigid total contact leg cast |
| Casting Supply |
| Procedure Code |
Description |
| Q4003 |
Cast supplies, shoulder cast, adult (11 years +), plaster |
| Q4004 |
Cast supplies, shoulder cast, adult (11 years +), fiberglass |
| Q4005 |
Cast supplies, long arm cast, adult (11 years +), plaster |
| Q4006 |
Cast supplies, long arm cast, adult (11 years +), fiberglass |
| Q4007 |
Cast supplies, long arm cast, pediatric (0–10 years), plaster |
| Q4008 |
Cast supplies, long arm cast, pediatric (0–10 years), fiberglass |
| Q4009 |
Cast supplies, short arm cast, adult (11 years +), plaster |
| Q4010 |
Cast supplies, short arm cast, adult (11 years +), fiberglass |
| Q4011 |
Cast supplies, short arm cast, pediatric (0–10 years), plaster |
| Q4012 |
Cast supplies, short arm cast, pediatric (0–10 years), fiberglass |
| Q4013 |
Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), plaster |
| Q4014 |
Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), fiberglass |
| Q4015 |
Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0–10 years), plaster |
| Q4016 |
Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0–10 years), fiberglass |
| Q4025 |
Cast supplies, hip spica (one or both legs), adult (11 years +), plaster |
| Q4026 |
Cast supplies, hip spica (one or both legs), adult (11 years +), fiberglass |
| Q4027 |
Cast supplies, hip spica (one or both legs), pediatric (0–10 years), plaster |
| Q4028 |
Cast supplies, hip spica (one or both legs), pediatric (0–10 years), fiberglass |
| Q4029 |
Cast supplies, long leg cast, adult (11 years +), plaster |
| Q4030 |
Cast supplies, long leg cast, adult (11 years +), fiberglass |
| Q4031 |
Cast supplies, long leg cast, pediatric (0–10 years), plaster |
| Q4032 |
Cast supplies, long leg cast, pediatric (0–10 years), fiberglass |
| Q4033 |
Cast supplies, long leg cylinder cast, adult (11 years +), plaster |
| Q4034 |
Cast supplies, long leg cylinder cast, adult (11 years +), fiberglass |
| Q4035 |
Cast supplies, long leg cylinder cast, pediatric (0–10 years), plaster |
| Q4036 |
Cast supplies, long leg cylinder cast, pediatric (0–10 years), fiberglass |
| Q4037 |
Cast supplies, short leg cast, adult (11 years +), plaster |
| Q4038 |
Cast supplies, short leg cast, adult (11 years +), fiberglass |
| Q4039 |
Cast supplies, short leg cast, pediatric (0–10 years), plaster |
| Q4040 |
Cast supplies, short leg cast, pediatric (0–10 years), fiberglass |
| Evaluations |
| Procedure 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 one to three performance deficits [eg, 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.
|
| 97166* |
Occupational therapy evaluation, moderate complexity, requiring these components:
- 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 three to five performance deficits [eg, 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. Patient 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.
|
| 97167* |
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 review of physical, cognitive, or psychosocial history related to current functional performance;
- An assessment[s] that identifies five or more performance deficits [eg, 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. Patient presents 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.
|
| 97168* |
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 |
| Procedure 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 |
Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises |
| 97124 |
massage, including effleurage, petrissage
and/or tapotement (stroking, compression, percussion) |
| 97129 |
Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes |
| 97130 |
Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure) |
| 97139 |
Unlisted therapeutic procedure (specify) |
| 97140 |
Manual therapy techniques (eg,
mobilization/manipulation, manual lymphatic drainage, manual traction), one
or more regions, each 15 minutes |
| 97150 |
Therapeutic procedure(s), group (2 or more
individuals) |
| 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 |
| 97535 |
Self-care/home management training (eg,
activities of daily living (ADL) and compensatory training, meal
preparation, safety procedures, and instructions in use of assistive
technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes |
| 97542 |
Wheelchair management (eg, assessment,
fitting, training), each 15 minutes |
| 97597* |
Removal of devitalized tissue from wound(s),
selective debridement, without anesthesia (eg, high pressure waterjet
with/without suction, sharp selective debridement with scissors, scalpel and
forceps), with or without topical application(s), wound assessment, and
instruction(s) for ongoing care, may include use of a whirlpool, per
session; total wound(s) surface area less than or equal to 20 square
centimeters |
| 97598* |
Total wound(s) surface area greater than 20
square centimeters |
| 97760 |
Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes |
| 97761 |
Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes |
| 97763 |
Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes |
| Modalities |
| Procedure Code |
Description |
| 90901 |
Biofeedback training by any modality |
| 97016 |
Application of modality to one or more areas;
vasopneumatic devices |
| 97018 |
paraffin bath |
| 97022 |
whirlpool |
| 97032 |
Application of a modality to one or more
areas; electrical stimulation (manual), each 15 minutes |
| 97033 |
iontophoresis, each 15 minutes |
| 97034 |
contrast baths, each 15 minutes |
| 97035 |
ultrasound, each 15 minutes |
* Procedure may not be provided by an occupational therapist assistant.
A unit of time is attained when the mid-point is passed. Providers should refer to the CPT guidelines for direction on reporting units on time-based and non-time-based procedures.
The same modality may not be reimbursed as
a PT service and an OT service on the same date of service for the same
member.
| E-Visits and Virtual Check-Ins |
| Procedure Code |
Description |
| G2250 |
Remote assessment of recorded video and/or images submitted by an established patient (eg, store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous seven days nor leading to a service or procedure within the next 24 hours or soonest available appointment |
| G2251 |
Brief communication technology-based service (eg, virtual check-in), by a qualified health care professional who cannot report Evaluation and Management services, provided to an established patient, not originating from a related service provided within the previous seven days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of clinical discussion |
| 98970 |
Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to seven days, cumulative time during the seven days; 5–10 minutes |
| 98971 |
Qualified nonphysician health care professional online digital assessment and management service, for an established patient, for up to seven days, cumulative time during the seven days; 11–20 minutes |
| 98972 |
Qualified nonphysician health care professional online digital assessment and management service, for an established patient, for up to seven days, cumulative time during the seven days; 21 or more minutes |
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