97533 sensory integration: notes and payers

For pediatric OT practice owners first, adult OT practices and their billers: 97533 reports one-on-one sensory integrative treatment in 15-minute units, and Medicare lists it as always therapy. Payment is a separate question; Aetna’s policy calls the therapy unproven. Bill the service delivered, read each plan’s written policy, and write goals as daily-life adaptive responses.⁠^1,2,3,4

What does CPT 97533 describe, and how is it counted?

97533 reports sensory integrative treatment given one on one: techniques that work on how a person takes in and organizes sensation, so they can respond to what daily settings ask of them, counted in 15-minute units of direct contact.⁠^1,5 The official descriptor is the American Medical Association’s copyrighted text, and CMS’s correct coding chapters open with that AMA notice, so what you read here is a plain-language summary.⁠¹² Read this page as education, not a coding decision: the CPT and HCPCS code sets in force and the payer’s written policy govern, and a certified coder or the payer answers for a particular claim.

On CMS’s 2026 therapy code list, where its entry dates from before 2006, 97533 is an always-therapy code, which means it is therapy whoever performs it and always carries GP, GO or GN to show the plan of care it was furnished under.⁠² For an occupational therapist that modifier is GO, for services delivered under an outpatient occupational therapy plan of care.⁠⁵ AOTA’s 2026 list of codes OT practitioners use includes 97533 among the one-on-one codes and reminds practitioners that not all codes are accepted by all payers.⁠¹

As a timed code, 97533 follows the payer’s unit method. Medicare adds the minutes of every 15-minute timed code given that day and converts the total: 8 to 22 minutes is one unit, 23 to 37 is two, 38 to 52 is three and 53 to 67 is four.⁠⁵ AOTA names the Medicare 8-minute rule and the AMA rule of 8s, or midpoint rule, as the two methods and says each payer decides which one applies; its code list adds that intervals of treatment at the same visit may be accumulated toward a service’s total time.⁠^1,13 The eight-minute rule guide works through the unit tables.

Medicare’s practitioner table of medically unlikely edits, effective October 1, 2026, allows 4 units of 97533 a day.⁠¹⁴ Its indicator marks a per-day edit based on clinical benchmarks, which a contractor may bypass when the record shows the extra units were actually provided, correctly coded and medically necessary.⁠⁸

How does 97533 differ from 97530, 97110, 97535 and 92526?

By what the clinician was treating, not by the swing, the mat or the room; Medicare’s note has to name each intervention in words a reviewer can compare with the claim.⁠⁴ The neighboring codes, in plain words:

• 97533, sensory integrative treatment: one-on-one work on how the person processes and responds to sensation, such as graded movement and heavy-work play that helps a child tolerate the noise and motion of a classroom transition.⁠¹
• 97530, therapeutic activities: dynamic, functional activities that improve performance, such as an obstacle course that builds the sequencing a child needs to climb playground equipment.⁠¹
• 97110, therapeutic exercise: exercise for strength, endurance, range of motion or flexibility, counted in 15-minute units.⁠¹
• 97535, self-care and home management training: dressing, meal preparation, safety routines or the use of adaptive equipment, one on one in 15-minute units.⁠¹
• 92526, swallowing and oral feeding treatment: an untimed code for swallowing function; a child who refuses foods by texture and is treated with sensory integrative techniques has had 97533, as the 92526 guide explains.⁠^1,8
• 97150, group treatment: two or more patients at once without one-on-one contact, so a sensory group is 97150, not 97533.⁠¹

When one session moves between two of these, keep each code’s minutes apart. Medicare divides the day’s timed units among the codes by the time each took, and NCCI bars reporting two physical medicine services for the same 15 minutes.⁠^5,12 The full code map is in the OT procedure codes guide, and telling 97110, 97112 and 97530 apart is in the 97110, 97112 and 97530 guide.

Can a physical therapist or an SLP report code 97533?

Only where the state practice act and the payer allow it, because Medicare’s code list does not settle scope. CMS lists 97533 as always therapy regardless of who performs it, so a PT would report it with GP under a PT plan of care, but the claims manual says the therapy modifiers do not allow a provider to deliver services they are not qualified and recognized by Medicare to perform.⁠^2,5 AOTA describes occupational therapy practitioners as playing a central role in sensory integration and processing across the lifespan.⁠¹⁵

For speech-language pathology the line is drawn by an edit. Under NCCI’s medicine chapter, the same practitioner cannot report 92507 or 92508 and 97533 on one date of service, though a billing entity that employs both an SLP and an OT may report each one’s own service that day with an NCCI-associated modifier.⁠¹² Put the state rule and each payer’s answer in the payer file before anyone other than an OT bills the code.

How does Medicare treat a 97533 claim?

Like any outpatient OT service: payable when the evaluation, plan of care and notes show a skilled, necessary service, and coded with GO. Medicare’s manual lists among occupational therapy services the planning and carrying out of therapeutic tasks to restore sensory-integrative function, with the example of motor and tactile activities that increase sensory input and improve response for a stroke patient whose functional loss has left a distorted body image.⁠⁴ Part B pays for outpatient OT furnished under a written plan of treatment, and the plan holds at minimum the diagnoses, the long-term goals, and the type, amount, duration and frequency of therapy.⁠^4,16

Medicare’s skilled-service test is not a diagnosis test. A beneficiary’s diagnosis or prognosis cannot be the sole factor in deciding whether a service is skilled; the key issue is whether a therapist’s skills are needed or the service could be carried out by nonskilled personnel.⁠⁴ For 2026, OT claims above $2,480 of the year’s OT services carry the KX modifier, confirming medical necessity as the record documents it, and claims over the threshold without it are denied; OT has its own amount, separate from the one PT and speech-language pathology share.⁠¹⁷

When an occupational therapy assistant furnishes 97533 in whole or in part, the line takes CO beside GO, and Medicare pays 85 percent of the otherwise applicable amount; the assistant’s independent minutes bring in the modifier once they pass 10 percent of the service.⁠^5,16,17 A Medicare Advantage plan’s prior authorization is limited by regulation to confirming the diagnoses or other criteria a coverage decision rests on, or checking medical necessity, and an approval given in advance cannot later be withdrawn on the ground that the service was not medically necessary.⁠¹⁸ Patients can read the same rules in plain terms in the Medicare therapy coverage guide.

Do commercial plans pay for sensory integration under 97533?

Not always, and each plan’s written policy is the answer, read before the first visit. Aetna’s Clinical Policy Bulletin 0256, in effect since May 29, 1998 and last reviewed April 15, 2026, considers sensory integration therapy experimental, investigational or unproven for communication, behavioral, emotional and learning disorders and for all other indications, and names 97533 as the CPT code not covered for the indications it lists.⁠³ The bulletin also says it is written to help administer plan benefits, is neither an offer of coverage nor a contract, describes benefits only in part and may change; its next review is set for March 11, 2027.⁠³

Do not generalize from one bulletin. Another plan may publish its own sensory integration policy, pay the service under its occupational therapy benefit, or say nothing at all; the written policy, the member’s benefit documents and a dated call reference are what the practice can rely on. AOTA’s code list tells practitioners to confirm payment policies with insurers before billing.⁠¹

The service drives the code, whatever a plan pays. NCCI’s general chapter forbids reporting a CPT code that does not accurately describe the service, and rules out a best-fit code unless it matches the service and every component of it was performed.⁠⁸ Calling a sensory integrative session 97530 or 97112 because the plan pays those codes puts a service on the claim that did not happen. Run the script below for each new plan, and again when a plan publishes a new review date.

What can a practice do when a plan excludes 97533?

Tell the family before treatment, lay out the choices that remain, and keep the coding honest. The choices that remain:

• Get the documents. A bulletin describes benefits only in part, so ask for the member’s plan documents as well as the policy.⁠³
• Code everything else as what it is. If the plan of care also targets self-care training or functional activities, those minutes take their own codes, and the sensory integrative minutes stay 97533.⁠⁸
• Offer self-pay with an estimate. A family with no benefits for the service, or one that chooses not to file a claim, is owed a written good faith estimate on request.⁠¹¹
• Use the appeal route. Ask the plan how to request reconsideration; AOTA’s 2023 position statement on sensory integration approaches for children and youth describes itself as a resource for funding and reimbursement sources, and the therapy denial appeal guide covers the family’s side.⁠¹⁹
• Check what state law reaches. Whether a state autism mandate applies to a child’s plan, and which services it names, is covered in the autism mandates guide.

How do Medicaid and EPSDT apply to 97533 for children?

Through EPSDT, which serves children under 21 enrolled in Medicaid and requires states to provide any 1905(a) service coverable under federal Medicaid law that is found medically necessary to treat, correct or reduce a condition, even when the state’s own plan does not list it.⁠²⁰ States decide medical necessity case by case, so a request for a child is judged on that child’s record.⁠²⁰ Under federal Medicaid rules, occupational therapy is prescribed by a physician or another licensed practitioner acting within state-law scope and delivered by or under the direction of a qualified occupational therapist, so collect the order or prescription your state requires before the first visit.⁠²¹

Then read the state’s Medicaid provider manual and fee schedule, or the child’s managed care plan manual, for whether 97533 is listed, how it is priced, which modifiers the state wants and what prior authorization applies, and keep a dated copy in the payer file. For what the program owes a child and how to document a request, see the EPSDT guide. If a child also receives OT at school or through early intervention, the IEP guide covers where outpatient care fits beside those services.

Which diagnosis code belongs on a 97533 claim?

The one the evaluation supports, within the clinician’s scope; there is no sensory processing disorder code to pick. The FY2027 ICD-10-CM files, in use for encounters from October 1, 2026 through September 30, 2027, have no index entry for sensory processing disorder or sensory integration disorder, and the tabular list contains neither term.⁠⁶ A 2025 review describes sensory processing as lacking a formal diagnosis in DSM-5 and the ICD classifications, and the sensory processing hub sets out its status in the diagnostic manuals with its own sources.⁠⁷

Medicare wants the evaluation to state a diagnosis where state and local law permit one, and notes that a medical diagnosis from a physician or NPP and an impairment-based treatment diagnosis are often both relevant, with the treatment diagnosis depending on the therapist’s scope.⁠⁴ The American Academy of Pediatrics (AAP) went further in a 2012 statement, advising against diagnosing sensory processing disorder for lack of an accepted diagnostic framework, calling for a thorough evaluation that considers other developmental and behavioral disorders, and noting that sensory difficulties appear in autism, ADHD, developmental coordination disorder and childhood anxiety disorders.⁠²² So the claim carries the conditions the physician and the evaluation actually support, and the functional problem the OT treats.

Never choose a diagnosis because a plan pays it. A diagnosis cannot by itself make a service skilled, different diagnoses are not grounds for a modifier that bypasses an edit, and a policy like Aetna’s, which covers sensory integration therapy for no indication, does not change with the diagnosis; its list of non-covered diagnosis codes includes the F84 range of pervasive developmental disorders and the F90 range for ADHD, and says it is not all-inclusive.⁠^3,4,8

What does the research on Ayres Sensory Integration show?

Benefit for autistic children’s individualized goals, no benefit for behaviors of concern, and continuing doubts about bias. A 2025 systematic review in the American Journal of Occupational Therapy included nine randomized trials with 344 children, each comparing ASI delivered to its Fidelity Measure with other care or none in children aged 0 to 12.⁠⁹ Five of the trials, in the authors’ grading, gave strong evidence that autistic children reach more of their individualized goals with ASI; three gave moderate evidence of no effect on behaviors of concern such as noncompliance or irritability. The authors flagged continuing risk of bias and asked for research in other groups of children.⁠⁹

The AAP took a cautious line on treatment in the same statement: sensory-based OT can be one piece of a comprehensive plan, but families should hear that research on its effectiveness is limited and inconclusive, and clinicians can offer a time-limited trial and teach families to judge the results.⁠²² AOTA’s Practice Smart recommendations add that sensory-based interventions should not be given to an individual child or youth without documented assessment results showing difficulty processing or integrating sensory information.⁠²³

Three things follow for billing and records. Goals belong in occupational performance, function and participation, where the review places ASI’s benefit, rather than in reducing behavior.⁠⁹ The trials studied ASI as its Fidelity Measure defines it, so a note that records what the session actually did tells a reviewer more than a label.⁠^4,9 And a review date in the plan of care answers the AAP’s trial-period advice.⁠²² The sensory integration evidence guide sets out the trials for families.

What should the evaluation and goals for 97533 show?

Documented assessment results, the client’s occupational profile, and goals written as adaptive responses inside daily occupations. Medicare asks the evaluation to document the need for therapy through objective findings and subjective self-report, and treats AOTA’s guidelines as guidelines, not policy.⁠⁴ AOTA recommends not starting OT intervention without the client’s occupational profile and collaborative goals, and not giving a child sensory-based interventions without documented assessment results.⁠²³ Objective evidence, in Medicare’s terms, means standardized assessment instruments, outcome measurement tools or measurable assessments of functional outcome.⁠⁴

Medicare’s manual says goals should be measurable and tied to identified functional impairments.⁠⁴ For 97533 that means naming the adaptive response the child or adult should show, in a named occupation, at a measurable level, rather than a sensory label. The pediatric assessment, as families meet it, is described on the sensory processing hub and its guide to how sensory processing is assessed; the adult side is in the adult sensory assessment guide. Leveling the OT evaluation itself is covered in the OT evaluation codes guide.

Parent and patient reports serve as measures when they are structured: a log the family keeps against a goal, a standardized questionnaire scored at the start and at each progress report, or a measure the family agreed to before treatment. Medicare recommends objective measures at the start of treatment and during or after it to quantify progress and justify continued care.⁠⁴

What should a 97533 session note record?

The intervention in words a reviewer can match to 97533, its minutes inside the day’s totals, what the clinician did that needed a therapist, and the response. For Medicare, each treatment note carries the treatment date, every intervention provided and billed in terms that can be checked against the claim, the total timed minutes alongside the total treatment time, and the signature and professional identification of the clinician, listing anyone else who contributed; the units billed have to agree with the timed minutes.⁠⁴ Only treatment time counts, so rest and toileting breaks come out of the minutes.⁠⁵

Show the skilled part. Medicare’s question is whether a therapist’s skills were needed or nonskilled personnel could have carried out the service, so the note names how the clinician graded the input, read the child’s or adult’s responses and changed the activity, not only which equipment was used.⁠⁴ A progress report, due at least once every 10 treatment days, assesses improvement toward each goal.⁠⁴

Can 97533 be billed with 97530 or 97110 on the same day?

Yes, under Medicare’s practitioner edits, when each was a distinct service in its own minutes. In the practitioner edit file effective October 1, 2026, version 323r0, the 97530 and 97533 pair carries a deletion date of December 31, 2021, and no edit pairs 97533 with 97110, 97112, 97535, 92526 or the OT evaluation codes 97165 to 97167.⁠¹⁰ Within a pair, CMS pays the column one code and denies the column two code unless a clinically appropriate modifier is on the claim; a modifier indicator of 0 shuts the pair off entirely, and 1 lets a modifier through in the right circumstances.⁠^8,10

A missing edit is not permission to double count. NCCI says that, with one exception, two physical medicine services may not be reported for the same 15 minutes, that its files do not contain every pair this rule forbids, and that practitioners are expected to code correctly where no edit exists.⁠¹² Where an edit does apply, 59 or XU may bypass it when the two procedures were performed in different timed intervals, even back to back in one visit; but a modifier may not be added only to get past an edit, and different diagnoses are not grounds for 59.⁠^8,12 Stringing together several services at the minimum billable length each, and billing a unit for every one, is also barred.⁠⁸

Recheck these pairs each quarter, since CMS posts changes to the edit files quarterly.⁠¹⁰ The January 2027 change matters in particular: ASHA reports that 92507 remains in effect through December 31, 2026 and that new speech treatment codes take effect January 1, 2027, so the 92507 row above describes 2026 claims.⁠²⁴ Ask every other payer whether it applies the NCCI edits or its own, and keep the answer in its file.

Which checks fit each payer type before a first 97533 visit?

Each payer type has its own written source, and the practice’s work is to find it, keep it and explain it. The table sets out the checks; the policy, manual or regulation in each row is the one to read.

How do you tell a family their plan does not pay for 97533?

Early, in writing, and with the choices laid out: what the plan’s policy says, what the evaluation recommends, what self-pay would cost and how to ask the plan to reconsider. The insurance and fees guide covers the practice’s wider payment wording; this is the 97533 version.

The good faith estimate rule reaches a family with no benefits for the service under their plan, and one that has benefits but chooses not to have a claim filed.⁠¹¹ Once a family asks about cost, the practice treats the question as a request for an estimate and owes it in writing within 3 business days; when a service is booked at least 3 business days ahead, the estimate is due within 1 business day of scheduling, or within 3 when it is booked at least 10 business days ahead.⁠¹¹ The estimate lists the expected service codes and charges, and one estimate can cover a recurring course of up to 12 months.⁠¹¹

Explain the evidence honestly as well. The AAP suggests telling parents that the research is limited and inconclusive and agreeing on a trial period with a way to judge it, and the 2025 review supports aiming therapy at individual goals rather than at behaviors of concern; a family deciding whether to pay deserves both points.⁠^9,22

When does an adult OT practice bill 97533?

When an adult’s evaluation documents a sensory integrative problem that limits daily occupations and the plan of care treats it with sensory integrative techniques; nothing in the code list or Medicare’s plan-of-care rules limits the code to children.⁠^2,4 Medicare’s own example of restoring sensory-integrative function is an adult after a stroke, given motor and tactile activities to increase sensory input and improve response.⁠⁴ AOTA describes OT practitioners’ role in sensory integration and processing as spanning the lifespan.⁠¹⁵

Three cautions shape the adult record. The randomized trials in the 2025 review were all in children aged 0 to 12, so an adult plan of care rests on the evaluation’s findings and measurable functional goals rather than on trial results.⁠^4,9 AOTA’s recommendation on documented assessment results is written for children and youth; hold adult treatment to the same standard, with the assessment documented first.⁠²³ And a commercial policy can reach adults, since Aetna’s bulletin covers sensory integration therapy for all indications, not only children’s conditions.⁠³

Under Medicare, the adult claim follows the GO, KX and CO rules above.⁠^5,17 What the adult assessment involves and produces is in the adult sensory assessment guide, and building adult referral sources is in the adult OT clients guide.

How would one child’s and one adult’s 97533 visits be coded?

From the note outward: what the clinician did, then the code, then the payer’s rules. Both cases are hypothetical, and their plans, policies and figures are inputs, not statements about any real plan.

Sources

1. American Occupational Therapy Association. 2026 Frequently Used CPT and HCPCS Codes for Occupational Therapy (AOTA coding list; code descriptors © 2026 American Medical Association). Checked October 25, 2026.
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   “The following CPT® and HCPCS G codes are frequently used by occupational therapy practitioners (OTPs) to report skilled services.”; “Not all codes are accepted by all payers. Always review state rules, consult the CPT® manual, and confirm payment policies with insurers prior to billing.”; “Codes listed are effective as of January 1, 2026.”; “For determining total time of a service, incremental intervals of treatment at the same visit may be accumulated.”; “To code services below, the OTP is required to have direct (one-on-one) face-to-face patient contact except where otherwise noted.”. The list gives 97533, 97530 and 97535 descriptors that name one-on-one patient contact and end “each 15 minutes”, places 97110 and 97112 among its therapeutic procedures counted in 15-minute units, describes 97150 as treatment of two or more patients without one-on-one contact, and lists 92526, swallowing and oral feeding treatment, with no unit of time.
2. Centers for Medicare & Medicaid Services. 2026 Therapy Code List and Dispositions (ZIP) (the CY 2026 list that CMS’s Therapy Services page points to through its Annual Therapy Update link; workbook CY_2026_Therapy_Code_List_and_Dispositions_v3.xlsx, Therapy Disposition Definitions and Therapy Update Code List tabs). Checked October 25, 2026.
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   “These codes are “always therapy” services, regardless of who performs them.”; “These codes always require a therapy modifier − GP, GO, or GN − to indicate that they’re furnished under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively.”; “Prior to 1/06”. The first two passages define disposition 5. In the code list tab, 97533 carries disposition 5 with the effective date quoted last; 92526, 97110, 97150, 97530 and 97535 also carry disposition 5.
3. Aetna. Sensory and Auditory Integration Therapy (Medical Clinical Policy Bulletin Number 0256). Checked October 25, 2026.
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   “Aetna considers sensory integration therapy and auditory integration therapy (also known as auditory integration training) experimental, investigational, or unproven for the management of persons with various communication, behavioral, emotional, and learning disorders and for all other indications.”; “The effectiveness of these therapies is unproven.”; “CPT codes not covered for indications listed in the CPB”; “ICD-10 codes not covered for indications listed in the CPB (not all-inclusive)”; “F84.0 - F84.9 Pervasive developmental disorders”; “F90.0 - F90.9 Attention-deficit hyperactivity disorders”; “Last Review 04/15/2026”; “Effective: 05/29/1998”; “Next Review: 03/11/2027”; “Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice.”; “This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract.”; “This Clinical Policy Bulletin may be updated and therefore is subject to change.”. 97533 is the one CPT code listed under the third passage’s heading.
4. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §§220.1.2, 220.2, 220.3 and 230.2). Checked October 25, 2026.
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   “The plan of care shall contain, at minimum, the following information as required by regulation”; “Diagnoses;”; “Long term treatment goals; and”; “Type, amount, duration and frequency of therapy services.”; “Goals should be measurable and pertain to identified functional impairments.”; “a beneficiary’s diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled.”; “The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel.”; “The initial evaluation, or the plan of care including an evaluation, should document the necessity for a course of therapy through objective findings and subjective patient self-reporting.”; “Utilize the guidelines of the American Physical Therapy Association, the American Occupational Therapy Association, or the American Speech-Language and Hearing Association as guidelines, and not as policy.”; “A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated.”; “In many cases, both a medical diagnosis (obtained from a physician/NPP) and an impairment based treatment diagnosis related to treatment are relevant. The treatment diagnosis may or may not be identified by the therapist, depending on their scope of practice.”; “Objective evidence consists of standardized patient assessment instruments, outcome measurements tools or measurable assessments of functional outcome.”; “Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment.”; “The minimum progress report period shall be at least once every 10 treatment days.”; “Assessment of improvement, extent of progress (or lack thereof) toward each goal;”; “Identification of each specific intervention/modality provided and billed, for both timed and untimed codes, in language that can be compared with the billing on the claim to verify correct coding.”; “Total timed code treatment minutes and total treatment time in minutes.”; “The billing and the total timed code treatment minutes must be consistent.”; “Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment”; “The planning and implementing of therapeutic tasks and activities to restore sensory-integrative function; e.g., providing motor and tactile activities to increase sensory input and improve response for a stroke patient with functional loss resulting in a distorted body image;”. The last passage is from §230.2’s list of occupational therapy services.
5. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and CORF/OPT Services (Pub. 100-04, §§20, 20.1, 20.2 and 20.3). Checked October 25, 2026.
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   “Therapy modifiers are GP for physical therapy, GO for occupational therapy, and GN for speech-language pathology.”; “These modifiers do not allow a provider to deliver services that they are not qualified and recognized by Medicare to perform.”; “GO Services delivered under an outpatient occupational therapy plan of care; or,”; “CO modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant”; “Several CPT codes used for therapy modalities, procedures, and tests and measurements specify that the direct (one on one) time spent in patient contact is 15 minutes.”; “For any single timed CPT code in the same day measured in 15 minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes.”; “2 units: ≥ 23 minutes through 37 minutes”; “3 units: ≥ 38 minutes through 52 minutes”; “4 units: ≥ 53 minutes through 67 minutes”; “If a service represented by a 15 minute timed code is performed in a single day for at least 15 minutes, that service shall be billed for at least one unit.”; “When more than one service represented by 15 minute timed codes is performed in a single day, the total number of minutes of service (as noted on the chart above) determines the number of timed units billed.”; “Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.”; “The time counted is the time the patient is treated.”; “The time the patient spends not being treated because of the need for toileting or resting should not be billed.”.
6. Centers for Medicare & Medicaid Services. ICD-10 Codes (page last modified September 8, 2026), with its 2027 Code Tables, Tabular and Index (ZIP) (files icd10cm_index_2027.xml and icd10cm_tabular_2027.xml). Checked October 25, 2026.
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   “Use these files for discharges occurring from October 1, 2026 – September 30, 2027 and for patient encounters occurring from October 1, 2026 – September 30, 2027.”; “The CDC develops and maintains ICD-10-CM.”; “ICD-10-CM INDEX TO DISEASES and INJURIES”. The last passage is the title of the 2027 index file. Neither the index nor the tabular list contains an entry for sensory processing disorder or for sensory integration disorder or dysfunction: the index’s sensory terms are subterms such as change, loss, neglect and dual sensory impairment, and the tabular list has neither phrase.
7. Grobelna N, Rutkowski R, Rybakowski F, Rybakowski J, Ferensztajn-Rochowiak E. The phenomenon of sensory processing: historical overview, theoretical models, and neurophysiological underpinnings (Acta Neurobiologiae Experimentalis, published January 14, 2025;84(4):359-370; doi:10.55782/ane-2024-2556; PMID 39812532; abstract read through the NCBI record). Checked October 25, 2026.
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   “There has been an interest in the relationship between SP and mental disorders in adults, despite the lack of a formal diagnosis in DSM‑5 and ICD classifications.”.
8. Centers for Medicare & Medicaid Services. NCCI Policy Manual for Medicare Services, Chapter I, General Correct Coding Policies (revision date January 1, 2026; sections E, T and V). Checked October 25, 2026.
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   “many policies are described using the term “physician.” Unless otherwise indicated, the use of this term does not restrict the application of policies to physicians only.”; “A modifier shall not be appended to a HCPCS/CPT code solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use.”; “A CCMI of “0” indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit”; “A CCMI of “1” indicates that NCCI PTP-associated modifiers may be used to bypass an edit under appropriate circumstances.”; “If 2 separate and distinct timed services are provided in separate and distinct time blocks, modifier 59 may be used to identify the services.”; “The practitioner is not permitted to perform multiple services, each for the minimal reportable time, and report each of these as separate UOS.”; “Additionally, different diagnoses are not adequate criteria for use of modifiers 59 or XE or XS.”; “A physician shall not report a CPT code for a specific procedure if it does not accurately describe the service performed. It is inappropriate to report the best fit HCPCS/CPT code unless it accurately describes the service performed, and all components of the HCPCS/CPT code were performed.”; “MUEs for HCPCS codes with an MAI of “3” are “per day edits based on clinical benchmarks.””; “If contractors have evidence (e.g., medical review) that UOS in excess of the MUE value were actually provided, were correctly coded and were medically necessary, the contractor may bypass the MUE for a HCPCS code with an MAI of “3” during claim processing, reopening, or redetermination”; “An MUE or the lack of an MUE, does not necessarily indicate coverage status of a HCPCS/CPT code.”.
9. Acuña C, Gallegos-Berrios S, Barfoot J, Meredith P, Hill J. Ayres Sensory Integration With Children Ages 0 to 12: A Systematic Review of Randomized Controlled Trials (American Journal of Occupational Therapy 2025;79(3):7903205180; doi:10.5014/ajot.2025.051023; PMID 40193295; abstract read through the NCBI record). Checked October 25, 2026.
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   “compared implementation of ASI with its Fidelity Measure™ with children ages 0 to 12 yr with treatment as usual, other treatment, or no treatment.”; “Nine RCTs (N = 344 participants), six with autistic children and three with other child populations, were included.”; “Strong evidence from five RCTs (four Level 1b) indicates that ASI supports autistic children in meeting their individualized goals.”; “Moderate evidence from three RCTs (two Level 1b) indicates no benefits of ASI for behaviors of concern, such as noncompliance or irritability.”; “Bias concerns persist among included studies.”; “ASI supports autistic children’s individualized goals related to occupational performance, function, and participation.”; “More research is needed to determine ASI’s benefits for other child populations.”.
10. Centers for Medicare & Medicaid Services. Medicare NCCI Procedure to Procedure (PTP) Edits (page last modified September 1, 2026, with the 2026 Quarter 4 practitioner edit file effective October 1, 2026: file 4, ccipra-v323r0-f4.txt, reached through the AMA license page for the ZIP). Checked October 25, 2026.
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    “If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied unless a clinically appropriate NCCI PTP-associated modifier is also reported.”; “CMS posts changes to each of its NCCI PTP published edit files on a quarterly basis.”; “Practitioner PTP Edits v323r0 (612,539 Records) 62292/01912 -- U0003/U0004 - Effective Oct. 1, 2026; Posted September 2, 2026”. In that file (column one/column two, then the modifier indicator, where the file’s key reads 0 for not allowed and 1 for allowed), the edits in effect with 97533 are 92507/97533 (effective October 1, 2020) and 92508/97533, indicator 1; 97150/97533, indicator 1; 97755/97533, indicator 1; 97533/97168, indicator 1; and 97533 over each of 97153, 97154, 97155, 97156, 97157 and 97158, indicator 0. The pair 97530/97533 carries a deletion date of December 31, 2021, and the file has no edit pairing 97533 with 97110, 97112, 97535, 92526, 97165, 97166 or 97167.
11. Electronic Code of Federal Regulations. 45 CFR 149.610, Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals (read through the eCFR versioner as of October 22, 2026; paragraphs (a)(2)(xiii), (b)(1), (c)(1) and (e)(1)). Checked October 25, 2026.
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    “An individual who does not have benefits for an item or service under a group health plan”; “but who does not seek to have a claim for such item or service submitted to such plan or coverage”; “shall consider any discussion or inquiry regarding the potential costs of items or services under consideration as a request for a good faith estimate”; “When a primary item or service is scheduled at least 3 business days before the date the item or service is scheduled to be furnished: Not later than 1 business day after the date of scheduling;”; “When a primary item or service is scheduled at least 10 business days before such item or service is scheduled to be furnished: Not later than 3 business days after the date of scheduling;”; “When a good faith estimate is requested by an uninsured (or self-pay) individual: Not later than 3 business days after the date of the request.”; “The scope of a good faith estimate for recurring primary items or services must not exceed 12 months.”; “Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service;”; “A good faith estimate must be provided in written form either on paper or electronically”. The first two passages are from the two parts of the rule’s definition of an uninsured (or self-pay) individual.
12. Centers for Medicare & Medicaid Services. NCCI Policy Manual for Medicare Services, Chapter XI, Medicine, Evaluation and Management Services, CPT Codes 90000-99999 (revision date January 1, 2026; sections H.3 and P). Checked October 25, 2026.
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    “Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2025 American Medical Association. All rights reserved.”; “A single practitioner shall not report CPT codes 92507”; “However, if the 2 types of services are performed by different types of practitioners on the same date of service, they may be reported separately by a single billing entity.”; “a provider entity that employs both types of practitioners may report both services using an NCCI PTP-associated modifier.”; “With one exception, providers/suppliers shall not report more than one physical medicine and rehabilitation therapy service for the same fifteen-minute time period.”; “These edits may be bypassed with modifier 59 or XU if the 2 procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter.”; “The NCCI program does not include all edits pairing 2 physical medicine and rehabilitation services (excepting “supervised modality” services) even though they shall not be reported for the same fifteen-minute time period.”; “Physicians are expected to code correctly even in the absence of NCCI PTP edits.”; “The re-evaluation services shall not be routinely reported during a planned course of physical or occupational therapy.”; “if the patient’s status should change and a re-evaluation is medically reasonable and necessary, it may be reported with modifier 59 or XU appended to CPT code 97164 or 97168 as appropriate.”. Item H.3, which the second to fourth passages come from, bars a single practitioner from reporting 92507 or 92508 on the same date of service as 97129, 97130 or 97533.
13. American Occupational Therapy Association. Timed CPT codes (Coding and Billing Resources, dated November 3, 2023; public summary). Checked October 25, 2026.
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    “There are two primary methods for determining how to assign units to that time”; “the Medicare 8-minute rule and the AMA rule of 8s or Midpoint Rule.”; “Individual payers will determine which method must be used when billing time for reimbursement.”; “It is the responsibility of the OT practitioner to understand payer rules on coding and billing the OT services they provide.”.
14. Centers for Medicare & Medicaid Services. Medicare NCCI Medically Unlikely Edits (MUEs) (page last modified August 31, 2026, with the Practitioner Services MUE Table effective October 1, 2026, file MCR_MUE_PractitionerServices_Eff_10-01-2026.csv). Checked October 25, 2026.
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    “An MUE is the maximum units of service (UOS) reported for a HCPCS/CPT code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service.”; “Not all HCPCS/CPT codes have an MUE.”; “Practitioner Services MUE Table (ZIP) - Effective October 1, 2026; Posted September 1, 2026”; “97533,4,3 Date of Service Edit: Clinical,Clinical: Data”. The last passage is the table row for 97533: code, practitioner MUE value, MUE adjudication indicator, rationale.
15. American Occupational Therapy Association. Sensory Integration & Processing (clinical topic page). Checked October 25, 2026.
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    “Occupational therapy practitioners play a central role in identifying and addressing sensory integration and processing challenges with clients across the lifespan.”; “supporting people’s participation in desired activities in home, school, and community settings”; “Sensory Integration Approaches for Children and Youth Within Occupational Therapy Practice (2023)”. The last passage is the title under which the page lists an AOTA official document.
16. Electronic Code of Federal Regulations. 42 CFR 410.59, Outpatient occupational therapy services: Conditions (read through the eCFR versioner as of October 22, 2026; paragraph (a)). Checked October 25, 2026.
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    “Medicare Part B pays for outpatient occupational therapy services only if they are furnished by an individual meeting the qualifications in part 484 of this chapter for an occupational therapist or an appropriately supervised occupational therapy assistant but only under the following conditions:”; “They are furnished under a written plan of treatment that meets the requirements of § 410.61.”; “Claims for services furnished in whole or in part by an occupational therapy assistant must include the prescribed modifier; and”; “claims for such services that include the modifier and for which payment is made under sections 1848 or 1834(k) of the Act are paid an amount equal to 85 percent of the amount of payment otherwise applicable for the service.”; “furnished by the occupational therapist assistant exceed 10 percent of the total minutes for that service (or unit of a service).”.
17. Centers for Medicare & Medicaid Services. Therapy Services (page last modified March 10, 2026). Checked October 25, 2026.
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    “the law preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.”; “there is one amount for PT and SLP services combined and a separate amount for OT services.”; “Claims for services over the KX modifier threshold amounts without the KX modifier are denied.”; “For CY 2026 this KX modifier threshold amount is:”; “$2,480 for PT and SLP services combined, and”; “$2,480 for OT services.”; “Payment for these services is at 85 percent of the otherwise applicable PFS payment amount/rate for the service, effective January 1, 2022.”; “portions of a service furnished by the PTA/OTA independent of the physical therapist/ occupational therapist (PT/OT), as applicable, that do not exceed 10 percent of the total service are not subject to the payment reduction”; “See the Annual Therapy Update link for the 2026 Therapy Code List and Dispositions.”. The 85 percent passage concerns PT and OT services furnished in whole or in part by physical therapist assistants and occupational therapy assistants.
18. Electronic Code of Federal Regulations. 42 CFR 422.138, Prior authorization (Medicare Advantage; read through the eCFR versioner as of October 22, 2026). Checked October 25, 2026.
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    “Prior authorization processes for coordinated care plans may only be used for one or more the following purposes:”; “To confirm the presence of diagnoses or other medical criteria that are the basis for coverage determinations for the specific item or service; or”; “For basic benefits, to ensure an item or service is medically necessary”; “it may not deny coverage later on the basis of lack of medical necessity”.
19. American Occupational Therapy Association. Sensory Integration Approaches for Children and Youth in Occupational Therapy Practice (AOTA Position Statement, American Journal of Occupational Therapy 2023;77(Suppl 3):7713410230; doi:10.5014/ajot.2023.77S3004; PMID 38175825; abstract read through the NCBI record). Checked October 25, 2026.
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    “This AOTA Position Statement describes the role of occupational therapy practitioners in providing services to children and youth with a variety of sensory processing patterns and sensory integrative dysfunction.”; “It also serves as a resource for policymakers, funding and reimbursement sources, and caregivers.”.
20. Centers for Medicare & Medicaid Services, Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment (Medicaid benefits page). Checked October 25, 2026.
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    “The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.”; “States are required to provide any additional 1905(a) services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan.”; “It is the responsibility of states to determine medical necessity on a case-by-case basis.”.
21. Electronic Code of Federal Regulations. 42 CFR 440.110, Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Medicaid; paragraph (b)(1), read through the eCFR versioner as of October 22, 2026). Checked October 25, 2026.
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    “Occupational therapy means services prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided to a beneficiary by or under the direction of a qualified occupational therapist.”.
22. Section on Complementary and Integrative Medicine; Council on Children with Disabilities; American Academy of Pediatrics; Zimmer M, Desch L. Sensory integration therapies for children with developmental and behavioral disorders (AAP policy statement, Pediatrics 2012;129(6):1186-1189; doi:10.1542/peds.2012-0876; PMID 22641765; abstract read through the NCBI record). Checked October 25, 2026.
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    “Because there is no universally accepted framework for diagnosis, sensory processing disorder generally should not be diagnosed.”; “Other developmental and behavioral disorders must always be considered, and a thorough evaluation should be completed.”; “Occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan.”; “parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive.”; “talking with families about a trial period of sensory integration therapy, and teaching families how to evaluate the effectiveness of a therapy.”; “Difficulty tolerating or processing sensory information is a characteristic that may be seen in many developmental behavioral disorders, including autism spectrum disorders, attention-deficit/hyperactivity disorder, developmental coordination disorders, and childhood anxiety disorders.”.
23. American Occupational Therapy Association. Practice Smart! (AOTA’s list of practice recommendations, which replaced its Choosing Wisely list). Checked October 25, 2026.
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    “AOTA’s Practice Smart! recommendations aim to help OT practitioners implement best practice by de-implementing the use of practices that are ineffective, unsafe, or not grounded in evidence.”; “Don’t provide sensory-based interventions to individual children or youth without documented assessment results of difficulties processing or integrating sensory information.”; “Don’t initiate occupational therapy interventions without completion of the client’s occupational profile and setting collaborative goals.”.
24. American Speech-Language-Hearing Association. Speech-Language Pathology Treatment Codes Replacing 92507 (ASHA coding resource). “CPT code 92507 remains in effect through December 31, 2026. The new codes take effect January 1, 2027.”; “Clinicians should not report the new codes before their effective date and should verify implementation requirements with each payer, as they may vary.”. Checked October 25, 2026.
25. DrSensory. DrSensory for Therapists (the For Therapists hub). Checked October 25, 2026.
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    “DrSensory is a directory families use free to find occupational therapy, physical therapy and speech therapy clinics”; “The directory lists clinics rather than individual therapists, so one listing covers a whole practice at one address.”; “the therapies you tick decide which condition and service tags you are offered, and ticking 18+ adds the adult ones.”; ““Verified” means the practice took a subscription and confirmed its own details. It does not mean DrSensory checked its clinical work.”.
26. DrSensory. Therapy Clinic Directory Pricing (the pricing page). Checked October 25, 2026.
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    “$29.99”; “Or $349.99 a year. Each additional location is $9.99 a month or $99.99 a year.”; “Ages and conditions treated”; “We do not verify clinical quality.”; “Listing is not an endorsement, and we say so publicly on every results page.”. The first passage is the monthly price shown for a listing; the third is a row of the table of what a claimed listing adds.
27. DrSensory. Sensory Processing Disorder: Signs, Subtypes, and Support (the sensory processing hub, section “Find a therapist who works with sensory processing”). Checked October 25, 2026.
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    “Practices in the DrSensory directory that name sensory processing or sensory integration among the services they offer, grouped by state.”; “Each practice appears here because its own listing names this among what it treats. A listing is not an endorsement or a referral, and inclusion does not mean we have verified a practice’s credentials, licensure or insurance”.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. CPT codes and their descriptors belong to the American Medical Association; the descriptions here are plain-language summaries, not the official text.