1. Medicaid Billing Module
Occupational Therapy Billing Form
August, 2017

2. Consent to Bill Medicaid
Prior to billing parents must provide written consent to release information and to bill for Medicaid reimbursement.
Consent is only good for one calendar year.
Parents are to be provided an annual notice.

3. Occupational Therapy Billing Form
Services must be documented on Service Care Plan signed by the parent and therapist.
Specific ICD-10 diagnosis codes are required. ICD-10 codes must relate to the specific type of therapy being provided. Think of these more as treatment diagnosis codes.
A global code such as Cerebral Palsy would not be sufficient.

4. Physician Authorization Form
Physician Authorization is required annually to bill for occupational therapy.
The OT listed suggested ICD-10 diagnosis codes that specifically relate to the therapy being provided.
When the physician signs the authorization form they are confirming the therapist’s code(s).
Authorizations can be signed by a Physician (MD or DO), Physician’s Assistant (PA) or by an Advanced Practice Registered Nurse (APRN).

5. Student Demographics Use the student’s real name as listed in WVEIS
The diagnosis code is to be an ICD-10 code that matches the need for occupational therapy.
County and school names can be written out or use the county and school WVEIS codes.
For provider name print the name of the person providing the service.

6. Procedure Codes Complete beginning and end dates for each procedure.
Enter the appropriate procedure code from those listed on the form. Use a separate line for each procedure code being provided during the month.
List the total number of units for the month for each procedure. (Units cannot be rounded but can be added together within the same calendar month)
The form is to be used for only one calendar month.

7. Procedure Code Changes
As of January 1, 2017, there is a new procedure codes for re-evaluations.
As of January 1, 2017, there are three separate procedure codes for an evaluation.
The evaluator must determine the complexity level of the evaluation choosing from low, moderate or high.
Only one of the three evaluations can be billed during the same calendar month.

8. Student Demographics and Procedures Sample
Medicaid Number
Last Name
First Name  
Doe
Jane
WVEIS #
Diagnosis Code
Date of Birth
County
1 Beginning Date
1 Ending Date
1 Procedure Code
Units
059
09/01/2015
09/30/2015
 97110 GO
 10
School
2 Beginning Date
2 Ending Date
2 Procedure Code
 203
97116 GO 5
Provider Name
3 Beginning Date
3 Ending Date
3 Procedure Code
 09/01/2015
 97168 GO  1

9. Explanation of Procedures and Caps Part 1
97165 GO
Occupational Therapy Evaluation Low Complexity
1 event per calendar year
97166 GO
Occupational Therapy Evaluation Moderate Complexity
97167 GO
Occupational Therapy Evaluation High Complexity
97168 GO
Occupational Therapy Re-evaluation
2 events per calendar year
97032 GO
Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
20 units per month
97110 GO
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility each 15 minutes
97112 GO
Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting and/or standing activities, each 15 minutes
97113 GO
Aquatic Therapy with therapeutic exercises, each 15 minutes

10. Explanation of Procedures and Caps Part 2
97116 GO
Gait training (includes stair climbing) each 15 minutes
20 units per month
97150 GO
Therapeutic procedure(s), group (2 or more individuals), each 15 minutes.
97140 GO
Manual therapy techniques (mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions each 15 minutes
97530 GO
Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance) each 15 minutes
97532 GO
Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider each 15 minutes
97533 GO
Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes

11. Start and Stop Times
Enter the start and stop times for each service on the corresponding date at the bottom of the form.
These will be used to easily identify dates billable services were conducted for students with transportation services.
If multiple procedure codes within a session or day, each procedure code needs to have a separate start and stop time. See the OT sample form for an example of how to document on the form.

12. Start and Stop Times Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Start
End Time
Date 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Start Time
End Time

13. Certified Occupational Therapy Assistant (COTA)
COTAs can only bill for therapy when an Occupational Therapist (OT) certified by the WV Board of Examiners is directly supervising.
Directly supervising requires the Board Certified OT to be on site when the therapy is being provided.
COTA progress/therapy logs are to be co-signed by the supervising OT for therapy dates that are billed for Medicaid. This only applies to dates when the OT was directly supervising the COTA. To make this clear to the person entering billing, the OT should initial the days that they provided direct supervision.
COTAs can not bill for evaluations.

14. Additional Documentation
Progress/therapy logs will also be required.
Original copies of progress/therapy logs must be on file in the special education central office.
There is not a required form for documentation of progress/therapy logs.

15. Signature and Credentials
Staff who provided or directly supervised the service will sign the form and list credentials.
For COTAs, the supervising OT must co-sign the billing form.

16. Terry Riley – Coordinator Office of Special Education tjriley@k12. wv
Terry Riley – Coordinator Office of Special Education ext WVDE Medicaid Website: