Occupational therapy coding and billing present many complexities and are also subject to changes every year. A new CPT code for cognitive function intervention has taken effect January 1, 2018 to replace another code. Occupational therapists (OTs) and speech-language pathologists (SLPs) can benefit greatly from the support of an experienced medical billing company for reporting new and existing codes, using modifiers correctly, and avoiding billing mistakes.
New CPT Code 97127 vs. Deleted CPT Code 97532
The new CPT code that has entered the scene in 2018 is: 97127, “Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact.”
This new CPT code replaces CPT code 97532, which can no longer be used by occupational therapists and others to bill for cognitive skills development to any payer.
While deleted CPT code 97532 described interventions used to improve cognitive skills (e.g., attention, memory, problem solving), the new CPT code 97127 expands the range to include areas that are within the scope of and frequently addressed by occupational therapy: executive function, reasoning, pragmatic functioning, and the use of compensatory strategies for managing the performance of activities. Other key points to note:
- Deleted CPT code 97532 was a timed code reported at 15-minute intervals
- New CPT code 97127 is not a 15-minute code; it is designed as a “per session,” or untimed code
- 97127 is only reported once on each claim
- 97127 should not be reported in conjunction with adaptive behavior treatment codes 0364T, 0365T, 0368T, 0369T
- CMS has developed its own, Medicare-specific code (G0515) to replace 97532.
Understanding the Broad Scope of Cognitive Function
The American Occupational Therapy Association points out that 97127 has a broader definition (compared to 97532) and was developed to report therapeutic interventions that reflect the concept of cognitive function.
Cognitive function plays a significant role in daily life at any age and includes a wide range and variety of mental processes such as perception, attention, memory, decision making, and language comprehension. While they improve from childhood to young adulthood, cognitive functions such as memory, attention, decision-making capabilities, and processing speed may decline as age increases. Various types of intervention programs are known to improve cognitive functions in healthy and nonhealthy children, young adults, and older adults.
New CPT code 97127 recognizes this broad scope of cognitive functions.
Medicare’s New G0515 Code
In the final 2018 Medicare Physician Fee Schedule, CMS stated that it considers CPT 97127 “invalid” and will not reimburse for it. The reason is that CMS is concerned about the untimed aspect of the new code.
The descriptor of Medicare’s new G0515 code reads: Development of cognitive skills to improve attention, memory (includes compensatory training), direct one-on-one patient contact, each 15 minutes
- G0515 matches code 97532 in terms of payment, value, descriptor language, and timed status as a 15-minute code.
- Medicare developed G-codes for specific programmatic needs that cannot be met using existing codes. G0515 should be reported the same way as a CPT code (in this case, 97532, before its deletion) on the claim form.
- Medicare will pay G0515 in 15-minute increments as it pays most other Physical Medicine and Rehabilitation CPT codes used by OT practitioners.
The American Speech-Language-Hearing Association (ASHA) provides additional information about G0515:
- Speech-language pathologists providing cognitive treatment services to Medicare patients, should report G0515 in the same manner that 97532 was reported.
- G0515 will be listed as a Medicare “sometimes therapy” code. SLPs should append the -GN modifier to indicate that G0515 was provided under a speech-language pathology plan of care.
- G0515 will count towards the therapy cap and is subject to the multiple procedure payment reductions (MPPR) policy.
- G0515 has no connection to the functional outcomes reporting system, which also uses G-codes.
- Similar to 97532, speech-language pathologists should not bill G0515 along with CPT code 92507 (speech, language, voice, communication treatment).
- Non-Medicare payers (i.e., Medicaid, Medicare Advantage or Part C, and private health insurance) may choose to implement either G0515 or 97127. Check with each non-Medicare payer to verify which code they will implement for cognitive treatment.
In addition to checking with non-Medicare payers regarding implementation of 97127, providers should also carefully review payer policies to ensure reimbursement rates for this new code are for a session, and not 15-minute units. Medical billing services are available to help with accurate reporting of cognitive function intervention by OTs and SLPs.