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24.5.10.2 Limitations
OT services must be billed with the AT modifier. Services must be provided according to the current (within 60 days) written orders of a physician and must be medically necessary. OT is billed using CPT procedure codes.
The AT modifier is described as "representing treatment provided for an acute condition, or an exacerbation of a chronic condition, which persists less than 180 days from the start of therapy." If the condition persists for more than 180 days from the start of therapy, the condition is considered chronic, and treatment is no longer considered acute. Providers may file an appeal for claims denied as being beyond the 180 days of therapy with supporting documentation that the client's condition has not become chronic and the client has not reached the point of plateauing.
Plateauing is the point at which maximal improvement has been documented and further improvement ceases. Use procedure codes C-97003 and C-97004 when billing for OT evaluation and re-evaluations.
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