Insurance Codes for OT with a Sensory-Based Approach

By Michelle Morris

Note: The first section of this information is available in the Sensory Integration Special Interest Section Quarterly Volume 22, number 1 March, 1999. Published by the American Occupational Therapy Association, Inc.

Insurance Reimbursement Survey Results

ICD-9 Diagnostic Codes that can be used

299.0 Autism
299.8 Pervasive Developmental Disorder/Asperger's Syndrome
314.0 Attention Deficit Disorder
314.01 Attention Deficit Disorder with Hyperactivity
315.4 Developmental Coordination Disorder
315.8 Delay in Development (specified)
315.9 Delay in Development (unspecified)
343.9 Cerebral Palsy
348.3 Encephalopathy
349.9 Unspecified Disorders of the Nervous System
382.9 Otitis Media
742.9 Unspecified Anomaly of the Brain, Spinal Cord and Nervous System
759.83 Fragile X Syndrome
781.3 Lack of Coordination
781.0 Tremors Nervous system
782.0 Disturbance of Skin Sensation
784.69 Motor Apraxia

CPT Codes that can be used for Treatment

97110 Therapeutic Exercises (procedures)
97112 Neuromuscular Re-Education
97530 Therapeutic Exercises (activities)
97770 Self-Care/Home Management

In a Private OT clinic recently surveyed, these are the evaluation and treatment codes most frequently used:

Evaluation Codes
96110 OT Eval- developmental assessment interpretation, report
96111 OT Eval- extended standardized developmental instruments
96115 Neurobehavioral status exam with interpretation report
96117 Neuropsychological testing with interpretation report
97003 Medicaid/CMS Evaluation

Treatment Codes:
97110 Therapeutic Procedure - develop strength/endurance. ROM/flex
97112 Neuro-muscular Re-Education - balance, coord.,proprio
97250 Myofascial Release/Mobilization - hand, wrist
97265 Joint Mobilization - hand wrist
97504 Orthotics Fitting - upper/lower extremity
97620 Prosthetic Training
97530 Therapeutic Activities - improve functional performance
97535 Self-Care/ADL Training
97537 Community Training
97532 Development of Cognitive Skills to Improve Attention Memory

Each insurance company has their own particular guidelines, and restrictions. Be sure you know the preferences of the insurance company before you bill for your clients. Some OTs who do fee for service help their clients by calling the insurance companies for them, even though the insurance goes to the parent not the OT.

Code: 97770 Sensory Integration/Cognitive Skills

yielded a wide response in the SI (SIS) survey, from 0% to 100% with an average of 57% reimbursement. However in many states this is an absolute 'NO' as it always brings a response of 'not covered'. This is a recent response one OT got back from Blue Sheild/ Blue Cross:

" The request for coverage for Occupational therapy is not approved. Sensory integration therapy is not covered as it is considered investigational by medical policy. Peer reviewed medical literature in support of this modality's efficacy and outcomes may be forwarded."

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