Combined therapy cap reached
Many plans pool OT with PT and speech under one visit limit. Core MB verifies the combined count at intake and monitors it across disciplines so care is authorized before the limit is reached.
Home / Specialties / Occupational Therapy
Occupational therapy medical billing services
Occupational therapy claims hinge on the evaluation tier, the GO modifier, timed units under the eight-minute rule and whether the note shows functional goals rather than exercise alone. Payers also combine OT with PT under a shared visit limit, so authorization tracking and certification timing decide whether the work gets reimbursed.
What makes occupational therapy billing different
Occupational therapy has code families, modifiers and payer habits that differ from PT in ways that matter on every claim.
- Evaluations are reported with 97165, 97166 and 97167 by complexity and 97168 for re-evaluation, and the occupational profile, assessment of performance deficits and decision making documented must match the level billed.
- Self-care and home management training under 97535, cognitive function interventions and therapeutic activities under 97530 are timed codes, so units follow total timed minutes and the note must describe functional tasks, not just exercise.
- Every service carries the GO modifier, Medicare's annual threshold applies with KX once crossed, and services furnished by an occupational therapy assistant are reported with the CO modifier at the reduced payment rate.
- Orthotic fabrication and fitting use 97760, 97761 and 97763, often paired with L-codes for custom splints, and payers require documentation of the device, the fitting time and the training provided to pay both lines.
Denials we see most in occupational therapy
Every denial gets a root cause, a fix and a feedback loop, so the same denial stops coming back.
Evaluation level not supported
Payers down-code 97167 when the note does not show multiple performance deficits and complex decision making. We review evaluation documentation against the tier criteria before the claim goes out.
Orthotic claim rejected
Splint claims fail when the L-code, 97760 and the supply are not aligned or when the device is not described. Core MB checks the note for device detail and bills the correct combination.
How Core MB bills for occupational therapy
Core MB runs occupational therapy billing from the treatment note forward, coding units from timed minutes, applying GO and CO where they belong and following every claim to payment. New therapists are credentialed in the same client portal while claims continue. Credentialing for new providers runs in the same system, tracked live in your client portal.
- Timed units are reconciled with documented minutes and functional goals before submission, with notes queried when goals are missing.
- Combined PT, OT and speech visit limits are tracked per patient so authorizations never lapse mid-plan.
- Pediatric OT claims to Medicaid and school-based payers are handled with their prior approval and modifier rules.
Everything in the service
Core MB provides the complete billing cycle for occupational therapy practices, from first verification call to final statement, with credentialing managed alongside.
- Insurance verification and eligibility checks
- Charge entry and specialty-specific coding review
- Claim scrubbing and electronic submission
- Payer follow-up on every open claim
- Denial management and appeals
- Payment posting and reconciliation
- Accounts receivable recovery
- Patient statements and balance support
- Monthly reporting you can read in five minutes
- Provider credentialing and payer enrollment
Occupational therapy billing questions
When should we use the CO modifier and how does it change payment?
Medicare requires CO on any line where an occupational therapy assistant furnished more than a small portion of the service, and those lines pay at a reduced rate. Core MB reads the signature and time entries to decide which lines need CO so claims are accurate and compliant without underbilling therapist-delivered care.
Why are our pediatric Medicaid claims being denied for prior approval?
Many state Medicaid programs and managed Medicaid plans require authorization for evaluations as well as treatment, and some count 97535 and 97530 separately. We confirm each plan's rules at verification, request authorization for the right codes and units, and track expirations so renewals are submitted early.
Can we bill an orthotic fitting and a custom splint the same day?
Yes, when the note documents fabrication or fitting time under 97760 or 97763 and describes the device billed with its L-code. Some payers bundle the training into the device. Core MB checks each payer's policy and prepares the supporting documentation so both components are considered.
How do we get started with Core MB for occupational therapy billing?
Complete the quote form with your setting, payer mix and software. We map a transition that runs new claims alongside your current billing so there is no gap in cash flow, and credentialing for new therapists or payer enrollments can begin at the same time in the same portal.
Occupational therapy billing that respects the note
Core MB codes OT claims from documented function and minutes, manages modifiers and caps, and follows every claim through, for practices anywhere in the country.