OT procedure codes for children and adults

For OT practice owners and billers serving children, adults or both, with PT and SLP owners sharing several codes: the service delivered picks the code. Many OT treatment codes are timed in 15-minute units, while evaluations, group treatment and 92526 are untimed. Medicare adds GO, CO and KX and applies NCCI edits; other payers set their own rules.⁠^1,2,3,4,5

What CPT codes do occupational therapists bill most often?

An outpatient OT practice reports mostly from the CPT physical medicine and rehabilitation series, the 97000 codes, plus a few from other sections such as 92526 for swallowing treatment and 96125 for cognitive testing, and the service the clinician delivered decides which one applies.⁠¹ CPT belongs to the American Medical Association, whose copyright notice appears in CMS’s own correct coding manual, so the table describes each code in plain words; the current CPT codebook holds the official descriptors.⁠¹⁴ This guide is educational: the payer’s policy and the current CPT and HCPCS code sets govern each claim, and a question about a specific claim goes to the payer or a certified coder.

The last column matters for every Medicare claim. CMS lists each code as “always therapy,” meaning it always carries the GP, GO or GN modifier of the plan of care it is furnished under, or “sometimes therapy,” meaning it becomes a therapy service, with the modifier, when a therapist furnishes it.⁠¹⁵ A code’s place on AOTA’s list of codes OT practitioners use is not a promise any payer pays it; AOTA’s own list says not all codes are accepted by all payers.⁠¹

How do 97110, 97112, 97530 and 97535 differ from each other?

They differ by what the skilled intervention was for, not by the equipment or the activity, so the treatment note has to say what the clinician was treating. Medicare’s manual says a diagnosis or prognosis cannot be the sole factor in deciding whether a service is skilled, and the same logic runs through code choice: the goal, the clinician’s skilled input and the patient’s response decide.⁠⁶

• 97110, therapeutic exercise: repeated, graded exercise aimed at an impairment such as weak grip, limited shoulder range or low endurance, for an adult after a wrist fracture or a teenager with juvenile arthritis.⁠¹
• 97112, neuromuscular reeducation: retraining balance, coordination, posture or body awareness, such as postural control work for a child with low tone or standing balance for an adult after a stroke.⁠¹
• 97530, therapeutic activities: dynamic, functional tasks that use several skills at once, such as a child sequencing a climbing and reaching course that builds toward playground participation, or an adult practicing reaching and carrying in a kitchen.⁠¹
• 97535, self-care and home management training: teaching the task itself or a way to compensate, such as dressing, bathing, toileting, meal preparation, safety routines or the use of adaptive equipment, for a child learning to manage fasteners or an adult learning one-handed dressing.⁠¹

The same climbing wall can sit under 97112 one week and 97530 the next if the goal changed, and the note should show that change. Where a session moves between two of these, count the minutes for each, since the unit rules divide the day’s timed minutes among the codes by the time each took.⁠⁴ When a case is borderline, read the full descriptors in the current CPT codebook rather than a summary.

When does an OT report 97533 for sensory integration?

When the clinician delivered one-on-one sensory integrative treatment, 97533 is the code, whatever a payer later decides to pay. CMS lists it as an always-therapy code, timed in 15-minute units on AOTA’s list.⁠^1,15 Coverage is a separate question: Aetna’s clinical policy bulletin on sensory and auditory integration therapy, last reviewed April 15, 2026, calls sensory integration therapy experimental, investigational or unproven and lists 97533 as not covered for the conditions it names.⁠¹³ Reporting sensory integrative treatment as 97530 because a plan pays 97530 would misstate the service; the honest steps are to check each plan’s policy before the visit, tell the family what the plan says, and keep a copy in the plan’s file.

A speech rule touches this code too. NCCI’s chapter on medicine services bars a single practitioner from reporting 92507 or 92508 on the same date as 97129, 97130 or 97533; when an SLP and an OT in the same practice each furnish their own service that day, the practice may report both with an NCCI-associated modifier.⁠¹⁴

When does an OT bill 97129, 97130, 96125 or 97755?

When the OT delivers cognitive strategy treatment (97129 and 97130), standardized cognitive testing (96125) or an assistive technology assessment with a written report (97755); each has its own counting rule. 97129 covers the first 15 minutes of cognitive function intervention and 97130 each further 15 minutes; ASHA’s coding page calls 97130 the add-on reported with 97129, never on its own, and Medicare’s daily unit edit for 97129 is 1.⁠^1,17,18 CMS lists both as sometimes-therapy codes, which become therapy, with GO, when an OT furnishes them under an OT plan of care.⁠¹⁵ Ask the payer how it wants 97129 and 97130 counted on a day with other timed codes.

96125 is standardized cognitive performance testing billed per hour, and ASHA notes that its time includes interpreting the results and preparing the report.⁠¹⁸ NCCI adds that a central nervous system test code cannot be reported for a self-administered test.⁠¹⁴ On the same date as an OT evaluation, 96125 is the column two code of an edit that allows a modifier, so the record needs a reason the test was a distinct service.⁠⁹

97755 is an assistive technology assessment with a written report, timed in 15-minute units.⁠¹ NCCI describes it as intended for severely impaired patients who need adaptive technology, and the October 1, 2026 edit file pairs it with the common one-on-one treatment codes and bars it outright beside an OT evaluation.⁠^9,14

Can an occupational therapist bill 92526 for feeding treatment?

The state’s OT practice act and the payer decide, not Medicare’s code list: CMS lists 92526 as an always-therapy code, whoever performs it, carrying the modifier of the plan of care it is furnished under, which is GO for an OT plan.⁠^4,15 The 92526 feeding and swallowing guide covers the code, its edits and the two professions’ positions in full. AOTA says occupational therapy practitioners play a crucial role in addressing feeding, eating and swallowing challenges across the lifespan, and NCCI’s chapter on medicine services names SLPs among those who perform 92526.⁠^14,19 Before an OT bills it, confirm the state’s scope rules and each payer’s policy, including a Medicare contractor’s local policy, and keep both in the payer file.

92526 is untimed: AOTA’s list gives it no unit of time, ASHA says an untimed code is billed once a day however long the service takes, and Medicare’s daily unit edit for it is 1.⁠^1,17,18 Two edits follow it. With 97110, 97112, 97150 or 97530 on the same date, 92526 is column one and a modifier is allowed only for a separate, documented service; with G0283, unattended electrical stimulation, no modifier is allowed.⁠^9,14 Building a feeding service is covered in the feeding and swallowing specialty guide.

Which codes cover orthotics, prosthetics and group treatment?

Orthotic and prosthetic training splits by encounter: 97760 for orthotic management and training at the first encounter, 97761 for prosthetic training at the first encounter, and 97763 for later encounters, each timed in 15-minute units.⁠¹ The October 1, 2026 edit file bars 97760 or 97761 with 97763 on the same date, with no modifier allowed.⁠⁹ CMS’s code list also says 97760 should not be reported with 97116, gait training, for the same extremity.⁠¹⁵

Group treatment is 97150: CMS pays for therapy furnished at the same time to two or more patients, who need not be doing the same activity, with the therapist in constant attendance but no one-on-one contact required.⁠⁶ CMS’s billing scenarios say that a therapist dividing attention among patients, with only brief, intermittent contact or the same instructions to several at once, bills each patient one untimed unit of 97150.⁠¹⁶ Running a group program is covered in the therapy groups guide.

How are the OT evaluation codes 97165 to 97168 chosen?

By complexity: 97165 for low, 97166 for moderate and 97167 for high, based on the occupational and medical history, the assessment and the clinical decision making, with 97168 for a re-evaluation under an existing plan of care.⁠²⁰ Each is untimed and carries GO for Medicare, an OT may report only one evaluation or re-evaluation on a date of service, and the evaluation itself is limited to one unit per episode of care.⁠^3,14,15

Evaluation and treatment may both be billed on the same day.⁠⁶ In the October 1, 2026 edit file, no live edit pairs 97530 with an OT evaluation, but 97750, 97755 and 97763 are barred beside any OT evaluation or re-evaluation, and the re-evaluation is the column two code beside several treatment codes; NCCI says a re-evaluation is not routinely reported during a planned course and, when the patient’s status changes, takes modifier 59 or XU.⁠^9,14 Choosing the complexity level, including the pediatric questions AOTA addresses, has its own guide coming in this series.

How are timed units counted for OT codes under Medicare?

Medicare adds up the day’s minutes of all 15-minute timed codes, then converts the total to units: 8 to 22 minutes is one unit, 23 to 37 is two, 38 to 52 is three, and the pattern continues.⁠⁴ The eight-minute rule guide works the full table and the per-code method some other payers use. Any timed service performed for at least 15 minutes gets at least one unit, and a remaining unit goes to the service with more leftover minutes, as in CMS’s example of 33 minutes of 97110 and 7 minutes of 97140 billed as two units of 97110 and one of 97140.⁠⁴ An untimed code is billed as one unit however long it runs.⁠⁴

Only treatment time counts. The minutes are the time the patient is treated, and rest or toileting breaks are not billed.⁠⁴ Two physical medicine services cannot be reported for the same 15 minutes, supervised modalities being the one exception, and the treatment note’s total timed minutes have to agree with the units billed.⁠^6,14 Age plays no part in the count: a payer that uses this method applies it to a child’s session and an adult’s the same way.

Do other payers count OT units the same way as Medicare?

Not necessarily. AOTA names two main methods for turning minutes into units, the Medicare 8-minute rule and the AMA rule of 8s, also called the midpoint rule, and says each payer decides which one applies.⁠² Ask every commercial plan, Medicare Advantage plan and Medicaid plan which method it uses, in writing if possible, and keep the answer in that plan’s file with the date. Bill each plan by its own method, even when the same session would produce a different unit count under another plan.

Which modifiers belong on an occupational therapy claim?

For Medicare, every OT service carries GO, the modifier for services delivered under an occupational therapy plan of care; PT services carry GP and speech-language pathology services GN.⁠⁴ The modifier names the discipline of the plan of care the service is delivered under, so a code furnished under an OT plan takes GO.⁠^4,15 Two more modifiers recur: CO, when an occupational therapy assistant furnishes a service in whole or in part, and KX, once the year’s OT spending passes the threshold.⁠^4,5

Medicare also reduces some payments on its own, without a modifier from the practice: the multiple procedure payment reduction pays the practice expense part of certain always-therapy services at 50 percent for each service that day except the one with the highest practice expense value.⁠⁵ For a CO line, the 15 percent reduction is taken last, after that one.⁠⁴ Ask each other plan whether it uses CO or its own assistant rules, and keep the answer.

When does the CO modifier apply to an OTA’s minutes?

When the assistant furnishes all of a service, or a portion of it on their own that is more than 10 percent of the service’s minutes; the claim then carries CO beside GO and Medicare pays the line at 85 percent of the otherwise applicable amount.⁠^4,5,8 Minutes the OT and OTA furnish together count as the OT’s.⁠³ The regulation sets two exceptions: when the OT furnishes 8 or more minutes of the last 15-minute unit, that unit is billed without CO, and when two units of one service remain and the OT and OTA each furnished 9 to 14 minutes, totaling 23 to 28, one unit takes CO and one does not.⁠⁸

CMS’s worked examples include OT cases. When an OTA furnishes 11 minutes of 97535 and the OT 11 minutes of 97530, only one unit can be billed, and the practice bills either 97530 without CO or 97535 with it.⁠³ When an OT and an OTA each run 20 minutes of a group on their own, each member’s 97150 carries CO.⁠³ In private practice, an OTA may work under the OT’s general supervision under Medicare’s regulation, within state law, and Medicare’s manual says OTAs may not provide evaluative or assessment services.⁠^6,8

What does the KX modifier threshold mean for OT in 2026?

It means each OT claim above $2,480 of the year’s OT services carries KX, confirming that the services are medically necessary and justified by the documentation; claims above the threshold without it are denied.⁠⁵ OT has its own amount, separate from the one PT and speech-language pathology share, so a patient seeing both an OT and a PT reaches each threshold on its own.⁠⁵ What the threshold means for patients, and the notice rules around it, are in the Medicare therapy coverage guide.

Which NCCI edits does an OT practice run into most often?

The ones that pair group treatment, assistive technology assessment, evaluations and orthotic encounters with the common treatment codes. In an edit pair, the column one code is paid and the column two code is denied unless a modifier is allowed and the circumstances justify one; an indicator of 0 means no modifier can bypass the edit and 1 means one can, in the right circumstances.⁠^7,9 The table reads the practitioner edit file effective October 1, 2026, version 323r0.⁠⁹

Some pairs that were edits in earlier years carry deletion dates in the same file: 97140 with 97530 was deleted as of December 31, 2019, and 97530 with 97533 or 97535 as of December 31, 2021.⁠⁹ The lack of an edit does not let two services share the same 15 minutes, and NCCI expects correct coding even where no edit exists.⁠¹⁴ CMS posts additions, deletions and modifier changes to the edit files each quarter, so recheck these pairs when a new quarter’s file appears.⁠⁹

When is modifier 59 or XU appropriate on an OT claim?

Only when the two services really were distinct and the note shows it. For physical medicine codes, NCCI allows modifier 59 or XU to bypass an edit when the two procedures were performed in different timed intervals, even one after the other in the same visit.⁠¹⁴ NCCI’s general rules add that a modifier may not be appended solely to bypass an edit, that a different diagnosis is not enough reason for 59, and that the medical record must meet the criteria of any modifier used; XE is only for a separate encounter on the same date.⁠⁷ A practitioner also may not perform several services for the minimum reportable time each and report each as a separate unit.⁠⁷ No modifier works on an edit with indicator 0.⁠⁷

What documentation supports each OT code family?

For Medicare, the daily treatment note records the date, each intervention by name for timed and untimed codes in words that can be compared with the claim, the total timed code minutes and the total treatment time, and the signature and credentials of the clinician, with each person who contributed.⁠⁶ Every timed service is recorded even when it is not billed, because it can change the billing, and the billing and the total timed minutes have to agree.⁠⁶ Total treatment time includes untimed codes, so a group or a 92526 session appears in it too.⁠⁶

The plan of care holds, at minimum, the diagnoses, the long-term goals, and the type, amount, duration and frequency of therapy, and a progress report is due at least once every 10 treatment days.⁠⁶ Certification of the plan and its timing are covered in the Medicare therapy coverage guide. Commercial and Medicaid plans publish their own documentation rules; where they ask for more, follow the stricter one.

How does OT coding work for children on Medicaid and EPSDT?

The codes are the same for a child as for an adult; what changes is the payer and what it covers. For a child under 21 in Medicaid, EPSDT requires the state to provide any service coverable under federal Medicaid law that is found medically necessary to correct or reduce a condition, even if the state’s own plan does not list it, and the state decides medical necessity case by case.⁠¹⁰ The EPSDT guide covers what the program owes children and what a pediatric practice documents.

Payment comes from the state’s fee schedule or the child’s managed care plan. Every state must publish its Medicaid fee-for-service rates on a public website, organized so anyone can find what Medicaid pays for a service, with pediatric and adult rates shown separately where they differ, starting no later than July 1, 2026.⁠¹¹ Read the schedule for each OT code you bill: whether it is listed, whether it is priced per unit or per visit, and which modifiers the state’s billing manual asks for. A managed care plan’s provider manual answers the same questions for its members.

Commercial plans that cover children write their own policies, which can exclude a code, as the 97533 example above shows.⁠¹³ Two pediatric edits deserve a check before a first visit: developmental testing codes 96112 and 96113 take column one over the OT evaluation codes, and 96125 is the column two code beside an OT evaluation.⁠⁹ Services a child receives at school under an IEP, or through the state’s early intervention program, are arranged under those programs; the IEP guide and the infant development programs guide cover where outpatient care fits beside them.

How does OT coding work for adults on Medicare Part B?

Outpatient OT under Medicare Part B follows the unit, modifier and edit rules above, with GO on every line.⁠^4,5,9 Coverage questions, including plan of care certification, treatment to maintain function and the patient’s costs, are in the Medicare therapy coverage guide.

Common adult cases map to codes covered above: 97760 and 97763 for orthosis training after a hand injury, 97535 for one-handed dressing after a stroke, 97129 and 97130 for cognitive strategy training after a brain injury, 97755 for an assistive technology assessment, and 92526 where state law and the payer let an OT treat dysphagia.⁠^1,15 AOTA keeps a separate list of the HCPCS Level II codes OT practitioners use to report fabricating, fitting or providing orthoses.⁠¹ The edit pairs around these codes are in the table above.

What changes under Medicare Advantage and home health?

Medicare Advantage plans may require prior authorization, but only to confirm the diagnoses or other medical criteria behind a coverage decision or to check that a basic benefit is medically necessary under the standards the regulation sets; once a plan approves a service, it may not later deny it for lack of medical necessity.⁠¹² A plan can also publish its own billing rules, so read its provider manual for the unit method, assistant modifiers and authorization steps, and keep the approval with the claim.

Home health is a different payment system. For a patient under a home health plan of care, payment for the covered services, therapy included, is part of the home health agency’s 30-day payment, and the agency provides those services directly or under arrangement and bills for them.⁠²¹ An agency bills outpatient therapy codes for people who are not homebound or not under a home health plan of care.⁠⁴ A practice asked to see a patient who is under a home health plan of care checks with the agency first.

How do you pick the right code for an OT session?

Start from what the clinician did and why, then find the code that describes that service, then check the payer’s rules; never the other way around. The table maps common OT session content to its code family for a Medicare claim.

What should an OT practice check before a claim goes out?

Check the codes against the note, the units against the minutes, the modifiers against who furnished what, and each pair of codes against the current quarter’s edits. Run all four on every claim before it goes, not after a denial.

Where do commercial and Medicaid plans differ from Medicare?

Wherever their own policies say so, which is why Medicare’s rules are a reference, not a default. The unit method can differ, since AOTA notes that each payer chooses between the Medicare method and the AMA midpoint rule.⁠² The CQ and CO assistant modifiers exist because the law required CMS to pay a reduced rate for assistants’ services, so ask each other plan whether it uses them.⁠⁵ A plan may exclude a code, as Aetna’s sensory integration policy does for 97533 in the conditions it names.⁠¹³ A state’s Medicaid schedule may pay some services through a bundled rate rather than code by code, and the regulation requires the state to publish that rate, so the schedule itself shows how each OT code is paid.⁠¹¹

Keep each answer, with the date and the name of the person or document that gave it, in that plan’s file, and recheck when the plan publishes a new policy. How to describe the result to families is in the insurance and fees guide, and using the plan’s allowed amounts in a rate discussion is in the reimbursement rates guide.

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

Each visit is coded from the note, unit by unit, then checked against the payer’s rules and the edit file. The two cases below are hypothetical, and their payers’ rules are inputs, not statements about any real plan.

Sources

1. American Occupational Therapy Association. 2026 Frequently Used CPT and HCPCS Codes for Occupational Therapy (coding list linked from AOTA’s frequently used CPT codes page; 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.”; “Codes listed are effective as of January 1, 2026.”; “For other HCPCS codes commonly used by OT practitioners to report fabrication, fitting, or provision of orthoses, please see AOTA’s SELECTED HCPCS LEVEL II CODES list.”; the list gives 97110, 97112, 97140, 97530, 97533, 97535, 97755, 97760, 97761 and 97763 in 15-minute units, 97129 for the first 15 minutes with 97130 as an add-on for each further 15 minutes, 96125 per hour, 97150 as untimed, and 92526 with no unit of time.
2. 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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   “Many occupational therapy (OT) procedures are billed through timed codes that capture individual units of time spent performing those services in 15-minute increments.”; “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.”.
3. Centers for Medicare & Medicaid Services. Billing Examples Using CQ/CO Modifiers for Services Furnished In Whole or In Part by PTAs and OTAs (page last modified February 26, 2026). Checked October 25, 2026.
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   “Services furnished by the PT together with the PTA or by the OT together with the OTA are considered to be performed by the PT/OT.”; “In the below examples (except Examples #H and #I for group therapy and RTM services, respectively) all services are for those therapy HCPCS/CPT codes that are described by 15-minute increments).”; “Either one unit of 97530 is billed without the CO modifier or one unit of 97535 is billed with the CO modifier.”; “The remaining minutes are for different services, so, bill the service with the greater number of minutes.”; “1 unit is billed for all untimed codes including evaluations, reevaluations, supervised modalities, group therapy”; “CPT code 97150 is billed with a CO modifier (for each patient) because the OTA’s minutes represents 50 percent of the total time for the group therapy services.”.
4. 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.”; “The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered:”; “CO modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant”; “The CQ modifier must be paired to the GP therapy modifier and the CO modifier with the GO therapy modifier.”; “The 15 percent reduction is taken last, e.g., after the MPPR (and other reductions where applicable) and right before sequestration.”; “When reporting service units for HCPCS codes where the procedure is not defined by a specific timeframe (“untimed” HCPCS), the provider enters “1” in the field labeled units.”; “A beneficiary received a total of 60 minutes of occupational therapy, e.g., HCPCS “timed” code 97530 which is defined in 15 minute units, on a given date of service.”; “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.”; “If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes, through and including 37 minutes, then 2 units should be billed.”; “3 units: ≥ 38 minutes through 52 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.”; “24 minutes of neuromuscular reeducation, code 97112,”; “33 minutes of therapeutic exercise (97110),”; “7 minutes of manual therapy (97140),”; “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 codes that are allowed one unit for “Allowed Units” in the chart below may be billed no more than once per provider, per discipline, per date of service, per patient.”; “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.”; “Home health agencies (HHAs) (to individuals who are not homebound or otherwise are not receiving services under a home health plan of care (POC).”; the §20.2 chart lists 97165, 97166, 97167 and 97168 with one allowed unit for OT.
5. Centers for Medicare & Medicaid Services. Therapy Services (page last modified March 10, 2026). Checked October 25, 2026.
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   “Just as with the incurred expenses for the therapy cap amounts, there is one amount for PT and SLP services combined and a separate amount for OT services.”; “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.”; “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.”; “Medicare applies a MPPR to the practice expense component of certain “always therapy” services. Since April 1, 2013, the MPPR rate is 50 percent for both practitioner/office and institutional settings. It applies to the second and subsequent therapy services provided to a patient on the same day.”; “The service with the highest PE relative value unit (RVU) is paid at 100% and the remaining services are paid at 50%.”; “requires CMS, using a new modifier, to make payment at a reduced rate for physical therapy and occupational therapy services that are furnished in whole or in part by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs).”; “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”.
6. 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, 230 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.”; “The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits.”; “a beneficiary’s diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled.”; “The minimum progress report period shall be at least once every 10 treatment days.”; “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.”; “Record each service provided that is represented by a timed code, regardless of whether or not it is billed, because the unbilled timed services may impact the billing;”; “Total timed code treatment minutes and total treatment time in minutes.”; “Total treatment time includes the minutes for timed code treatment and untimed code treatment.”; “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”; “Contractors pay for outpatient physical therapy services (which includes outpatient speech-language pathology services) and outpatient occupational therapy services provided simultaneously to two or more individuals by a practitioner as group therapy services (97150).”; “The individuals can be, but need not be performing the same activity.”; “The physician or therapist involved in group therapy services must be in constant attendance, but one-on-one patient contact is not required.”; “OTAs may not provide evaluative or assessment services, make clinical judgments or decisions; develop, manage, or furnish skilled maintenance program services; or take responsibility for the service.”; “They act at the direction and under the supervision of the treating occupational therapist and in accordance with state laws.”.
7. Centers for Medicare & Medicaid Services. NCCI Policy Manual for Medicare Services, Chapter I, General Correct Coding Policies (effective January 1, 2026; section E, Modifiers and Modifier Indicators). Checked October 25, 2026.
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   “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.”; “Documentation in the medical record must satisfy the criteria required by any NCCI PTP-associated modifier used.”; “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.”; “This modifier shall only be used to describe separate encounters on the same date of service.”.
8. Code of Federal Regulations. 42 CFR 410.59, Outpatient occupational therapy services: Conditions (eCFR, up to date as of October 22, 2026; paragraphs (a)(4)(i) to (v) and (c)(2)). Checked October 25, 2026.
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   “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.”; “Furnishes all the minutes of a service exclusive of the occupational therapist; or”; “such that the minutes for that portion of a service (or unit of a service) furnished by the occupational therapist assistant exceed 10 percent of the total minutes for that service (or unit of a service).”; “when the occupational therapist provides more than the midpoint of a 15-minute timed code, that is, 8 or more minutes, regardless of any minutes for the same service furnished by the occupational therapy assistant.”; “the occupational therapist and occupational therapy assistant each provided between 9 and 14 minutes of the service with a total time of at least 23 minutes and no more than 28 minutes, one unit of the service is billed with the prescribed modifier”; “Occupational therapy services may be performed by an occupational therapy assistant under the general supervision of the occupational therapist in private practice;”.
9. Centers for Medicare & Medicaid Services. Medicare NCCI Procedure to Procedure (PTP) Edits (2026 Quarter 4 practitioner file, version 323r0). 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 0 is not allowed and 1 is allowed): 97150 with 97110, 97112, 97140, 97530, 97533, 97535, 97760, 97761 and 97763, indicator 1; each of 97165 to 97168 with 97750, 97755 and 97763, indicator 0; 97166/97165, 97167/97165, 97167/97166 and each of 97165 to 97167 with 97168, indicator 0; each of 97165 to 97168 with 96125, indicator 1; 96112 and 96113 with each of 97165 to 97168, indicator 1; 97129, 97130, 97533, 97535, 97760 and 97761 each with 97168, indicator 1; 97755 with 97110, 97112, 97140, 97530, 97533, 97535, 97760, 97761 and 97763, indicator 1; 97760/97763 and 97761/97763, indicator 0; 97760 and 97763 each with 97110, 97112 and 97140, indicator 1; 97530 with 97537, 97542 and 97750, indicator 1; 92526 with 97110, 97112, 97150 and 97530, indicator 1; 92526/G0283, indicator 0; 92507 and 92508 each with 97129, 97530 and 97533, indicator 1; the pair 97140/97530 carries a deletion date of December 31, 2019, and the pairs 97530/97533 and 97530/97535 carry a deletion date of December 31, 2021; the rows pairing 97530 with 97165, 97166 and 97167 carry a deletion date equal to their effective date, January 1, 2020, and the current row pairing 97530 with 97168 carries a deletion date equal to its effective date, October 1, 2020.
10. Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment (Centers for Medicare & Medicaid Services). 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.”.
11. Code of Federal Regulations. 42 CFR 447.203, Documentation of access to care and service payment rates (Medicaid; eCFR, up to date as of October 22, 2026; paragraph (b)(1)). Checked October 25, 2026.
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    “The State agency is required to publish all Medicaid fee-for-service fee schedule payment rates on a website that is accessible to the general public.”; “Medicaid fee-for-service payment rates must be organized in such a way that a member of the public can readily determine the amount that Medicaid would pay for a given service.”; “In the case of a bundled payment methodology, the State must publish the Medicaid fee-for-service bundled payment rate”; “If the rates vary, the State must separately identify the Medicaid fee-for-service payment rates by population (pediatric and adult), provider type, and geographical location, as applicable.”; “The initial publication of the Medicaid fee-for-service payment rates shall occur no later than July 1, 2026”.
12. Code of Federal Regulations. 42 CFR 422.138, Prior authorization (Medicare Advantage; eCFR, up to date 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 based on standards specified in § 422.101(c)(1), or”; “it may not deny coverage later on the basis of lack of medical necessity”.
13. Aetna. Sensory and Auditory Integration Therapy (Medical Clinical Policy Bulletin 0256; last review April 15, 2026). 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.”; “CPT codes not covered for indications listed in the CPB:”; code 97533 is the one listed under that heading.
14. Centers for Medicare & Medicaid Services. NCCI Policy Manual for Medicare Services, Chapter XI, Medicine and Evaluation and Management Services (effective January 1, 2026; revision date 1/1/2026; sections H, M, P and V). 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.”; “Speech language pathologists may perform services coded as CPT codes 92507, 92508, or 92526.”; “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.”; “The NCCI PTP edit (92526/G0283) for MACs does not allow use of NCCI PTP-associated modifiers with this edit because the same provider would never perform both of these services on the same date of service.”; “In order to report a CNS assessment/test CPT code, the test cannot be self-administered.”; “An occupational therapist may report only one evaluation/re-evaluation (CPT codes 97165-97168) on a single date of service.”; “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 only exception involves a “supervised modality” defined by CPT codes 97010-97028, which may be reported for the same fifteen-minute time period as other therapy services.”; “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.”; “is intended for use on severely impaired patients requiring adaptive technology.”; “are not separately reportable for the same date of service with a physical therapy evaluation/re-evaluation CPT code (e.g., 97161-97164) or occupational therapy evaluation/re-evaluation CPT code (e.g., 97165-97168) when the 2 services are performed by a single practitioner or 2 practitioners of the same specialty.”; “occupational therapy evaluation (CPT codes 97165-97167) shall not be reported with more than one unit of service per episode of care.”; “occupational therapy re-evaluation (CPT code 97168) shall not be reported with more than one unit of service per date of service.”; section H.3 bars a single practitioner from reporting 92507 or 92508 on the same date as 97129, 97130 or 97533; section P.8 names 97750, 97755 and 97763 in the first passage on evaluations.
15. Centers for Medicare & Medicaid Services. Annual Therapy Update (page last modified March 4, 2026, with its 2026 Therapy Code List and Dispositions file). Checked October 25, 2026.
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    “The files on this web page contain the list of codes indicating whether they are sometimes or always therapy services.”; “These codes are “always therapy” services, regardless of who performs them.”; “These HCPCS/CPT codes represent “sometimes therapy” services. However, these codes are “always therapy” services when furnished by a therapist”; “CPT code 97760 should not be reported with CPT code 97116 for the same extremity.”; in the 2026 list, codes 92526, 96125, 97110, 97112, 97140, 97150, 97530, 97533, 97535, 97755, 97760, 97761 and 97763 carry disposition 5 (always therapy), 97129 and 97130 carry disposition 7 (sometimes therapy), and 97165 to 97168 carry disposition 5 and disposition 9 with the GO modifier.
16. Centers for Medicare & Medicaid Services. 11 Part B Billing Scenarios for PTs and OTs (Individual vs. Group Treatment; marked “Reviewed 9/2009” and linked from the Therapy Services section). Checked October 25, 2026.
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    “If the therapist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, it is appropriate to bill each patient one unit of group therapy, 97150 (untimed).”.
17. 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). 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.”; the table gives a value of 1 for 92526, 97129, 97150, 97165, 97166, 97167 and 97168.
18. American Speech-Language-Hearing Association. Medicare Coding Rules for SLP Services (Reimbursement, Medicare). Checked October 25, 2026.
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    “An untimed code is billed once per day, regardless of the time spent providing the service.”; “timed codes include a time designation in the descriptor”; “An exception is 96125, where allowable time includes interpretation of test results and preparation of the report.”; “This is a timed code for each hour of standardized testing.”; “This is the add-on code to report in conjunction with 97129. Don’t bill 97130 separately.”; “SLPs cannot report 97129 and 97130 on the same day as 92507.”.
19. American Occupational Therapy Association. Occupational therapy and feeding, eating, and swallowing (clinical topic page). “Occupational therapy practitioners play a crucial role in addressing feeding, eating, and swallowing challenges for clients across the lifespan.”; “Occupational Therapy interventions support the skills needed for safe and effective eating and swallowing.”. Checked October 25, 2026.
20. American Occupational Therapy Association. FAQs for coding pediatric OT evaluations (Coding and Billing Resources; public summary). “The OT evaluation CPT ® codes describe evaluation complexity of low, moderate, or high, based on criteria under three evaluation components, including the level of occupational/medical history, patient assessment, and clinical decision making.”. Checked October 25, 2026.
21. Centers for Medicare & Medicaid Services. Home Health PPS (page last modified July 2, 2026). Checked October 25, 2026.
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    “Beginning on January 1 2020, HHAs are paid a national, standardized 30-day period payment rate if a period of care meets a certain threshold of home health visits.”; “For individuals under a home health plan of care, payment for all services (nursing, therapy, home health aides and medical social services)”; “is included in the HH PPS base payment rates.”; “HHAs must provide the covered home health services (except DME) either directly or under arrangement, and must bill for such covered home health services.”.
22. DrSensory. DrSensory for therapists (the For Therapists hub). Checked October 24, 2026.
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    “DrSensory is a directory families use free to find occupational therapy, physical therapy and speech therapy clinics”; “across all 50 states and Washington, DC”; “Every clinic keeps a basic listing at no cost.”; “The directory lists clinics rather than individual therapists, so one listing covers a whole practice at one address.”; “Claiming is free and has three steps: find your listing, confirm your email with a six-digit code, choose a password.”; “There is no contract, and nothing is charged while you claim.”; “Therapy and developmental resources for children and adults, plus a directory of providers across the United States.”.
23. DrSensory. Therapy Clinic Directory Pricing (the pricing page and its frequently asked questions). Checked October 24, 2026.
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    “Outpatient physical therapy, occupational therapy, and speech-language pathology clinics. The directory lists clinics rather than individual therapists, so one listing covers your whole practice. Inpatient rehabilitation facilities and chiropractic practices are not listed.”; “$29.99 a month or $349.99 a year for your first location, and $9.99 a month or $99.99 a year for each additional location”; “Claiming your listing is free.”; “A description in your own words”; “We do not verify clinical quality”; “A listing means a practice appears in the directory. It is not a recommendation”; “Families never pay to search it or to contact a clinic”; “When a family writes from your profile, the address you gave for family inquiries is told that a message is waiting; you read it signed in, because what a parent writes about their child is health information, and you reply from your own address.”.

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 is the American Medical Association’s code set, and the code descriptions here are plain-language summaries, not the official descriptors.