Who has the authority to assign ICD-9-CM codes for billing?
Occupational therapists should NOT diagnose and treat anyone without a referral or certification for treatment from a physician unless permitted by state law. In general, OTs do not initially diagnose a condition, but may identify a treatment diagnosis for the purpose of billing. Check with your state’s practice act to verify whether or not a referral must be obtained prior to the initiation of services. The primary diagnosis or condition should be obtained from the physician, social worker, nurse practitioner, psychologist, etc. Examples of this type of diagnosis would be developmental delay or cerebral palsy. While this is the diagnosis that opens the case for occupational therapy services, it might not be the reason that a child is referred for occupational therapy. An occupational therapist would list a treatment (ICD-9-CM) code on the billing form in addition to the medical diagnosis. The documentation (and subsequent CPT codes) should reflect this secondary diagnosis. It is appro
