Occupational Therapy (CPB 0250, reviewed 2026-05-19)

By 2026-05-19: Billing team must implement the following changes: (1) Update billing system to require detailed documentation of medical necessity for all OT claims (CPT 97140, 97165-97168, 97535; HCPCS G0129, G0152, G0160, S9129, G0158, G2169), including objective evidence of improvement within 1 month of therapy start; (2) Add mandatory fields to encounter forms requiring providers to document: specific condition being treated, measurable baseline functional status, anticipated timeline for improvement, written plan of care, and provider supervision type; (3) Configure system to flag and deny claims lacking this documentation or showing no measurable progress; (4) Train providers and clinical staff that OT is non-covered once maximal benefit achieved, therapy transitions to home program, condition plateaus, or patient shows lack of participation; (5) Verify all OT providers are duly licensed and certified in their jurisdiction; (6) For home-based OT (G0152, G0160, S9129, G0158, G2169), confirm member is homebound and check plan limits (many HMO/QPOS plans capped at 60 days per condition per contract year); (7) Exclude OT coverage for educational settings and driver training per policy exclusions. Failure to obtain or maintain complete documentation will result in claim denials. Billing team responsible for system updates; providers responsible for documentation compliance.