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Texas School-Based Services Occupational Therapy 

Referral

In order for a student to receive OT through SHARS, the name and complete address or the provider identifier of the licensed physician who prescribed the OT must be provided.

Providers

OT must be provided by a professional who is licensed by the Texas Board of Occupational Therapy Examiners or an occupational therapy assistant (OTA) acting under the supervision of a qualified occupational therapist.

Services

OT includes:

  • Improving, developing, maintaining, or restoring functions impaired or lost through illness, injury, or deprivation.
  • Improving the ability to perform tasks for independent functioning when functions are impaired or lost.
  • Preventing, through early intervention, initial or further impairment or loss of function.

Evaluation

OT evaluation services include determining what services, assistive technology, and environmental modifications a student requires for participation in the special education program.

If an evaluation is performed over several days, the provider must submit the same evaluation procedure code for each evaluation session. The procedure code submitted must reflect the complexity level of the entire evaluation.

The therapist who performs the evaluation should use professional clinical judgment to decide which evaluation code to use. The selection of low (procedure code 97165), moderate (procedure code 97166), or high complexity (procedure code 97167) evaluation codes must be based on professional clinical judgment and may not be made by staff other than the rendering therapist.

Session Notes

Session notes are not required for procedure codes 97165, 97166, and 97167; however, documentation must include the billable start time, billable stop time, total billable minutes, and must note the activity that was performed (e.g., OT evaluation).

Session notes are required for procedure codes 97530 and 97150. Session notes must include the billable start time, billable stop time, total billable minutes, activity performed during the session, student observation, and the related IEP objective.

Reimbursement

The occupational therapist or COTA can only bill for time spent with the student present, including time spent assisting the student with learning to use adaptive equipment and assistive technology.

Time spent without the student present, such as training teachers or aides to work with the student (unless the student is present during the training time), report writing, and time spent manipulating or modifying the adaptive equipment is not billable.

POS

Procedure Code

Individual or Group

OT or OTA

1, 2, or 9

97165, 97166, and 97167

Individual

OT

1, 2, or 9

97150 with modifier GO

Group

OT

1, 2, or 9

97150 with modifier GO and U1

Group

OTA

1, 2, or 9

97530 with modifier GO

Individual

OT

1, 2, or 9

97530 with modifier GO and U1

Individual

OTA

Place of Service: 1=office; 2=home; 9=other locations

The recommended maximum billable time for OT evaluation is three hours, which may be billed over several days within a thirty (30) day period. The recommended maximum billable time for direct therapy (individual or group) is a total of one hour per day. Providers must submit documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

Citation

Texas Medicaid Provider Handbook

Children’s Services

August 2019

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