Research Article

Occupational Therapy Service Delivery

Importance: Rates of occupational therapy service utilization among people with autism spectrum disorder (ASD)
or intellectual disability (ID) have not been explored in population-based samples.

Objective: To describe occupational therapy services delivered to Medicaid-eligible persons younger than age 65
yr identified as having ASD, ID, or both and to evaluate demographic factors associated with occupational therapy
service utilization in this population.

Design: Retrospective, case–control, cohort study using claims records from Medicaid Analytic eXtract files
(2009–2012).

Setting: Data from all 50 states and Washington, DC.

Participants: Beneficiaries identified as having ASD only, ASD1ID, or ID only who were younger than age 18 yr
(N 5 664,214) and ages 18–64 yr (N 5 702,338).

Outcomes and Measures: We analyzed Current Procedural Terminology ® and Healthcare Common Procedure
Coding System procedure codes, Medicaid Statistical Information System type of service codes, and Center for
Medicare & Medicaid Services provider specialty codes.

Results: Only 3.7% to 6.3% of eligible adult beneficiaries received occupational therapy; in contrast, 20.5% to
24.2% of children received occupational therapy. Significant predictors of service use varied by group; however,
differences by race–ethnicity, eligibility on the basis of poverty, and geographic location were observed. Among
children, the most frequent billing code was for “therapeutic activities” (43%–60%); among adults, it was
“community/work reintegration training” (29%–39%).

Conclusions and Relevance: Billed procedure code patterns do not consistently reflect the unique occupational
focus that occupational therapy providers deliver to people with developmental disabilities. Disparities in
occupational therapy receipt warrant further attention to understand the social and structural factors affecting
service delivery.

What This Article Adds: Occupational therapy services paid for by Medicaid are used more frequently by children
with ASD and ID than by adults with these diagnoses. Greater understanding of the intersectional factors that drive
service delivery and disparities is needed.
Benevides, T. W., Tao, S., Becker, A., Verstreate, K., & Shea, L. (2022). Occupational therapy service delivery among Medicaid-enrolled children and
adults on the autism spectrum and with other intellectual disabilities. American Journal of Occupational Therapy, 76, 7601180100. https://doi.org/
10.5014/ajot.2022.049202

ccupational therapy, as a habilitation profession frequently use occupational therapy services, and a
O (American Occupational Therapy Association,
2020), addresses outcomes that are valued by people
great deal of research details specific intervention
approaches used by pediatric occupational therapy
on the autism spectrum and with related developmen- practitioners (e.g., sensory integration; Watling &
tal disabilities. Children on the autism spectrum Hauer, 2015). However, rates of occupational therapy

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JANUARY/FEBRUARY 2022, VOLUME 76, NUMBER 1 1
service utilization decline significantly in adolescence therapy practice and policy changes for autistic people
(Cidav et al., 2013) despite occupational therapy prac- and those with related developmental conditions, a
titioners having the skills to address outcomes valued large U.S. study of national scope is needed to docu-
by autistic individuals,1 including mental health, qual- ment the frequency of occupational therapy service
ity of life, sleep, activities of daily living (ADLs), and utilization by age and other demographic characteris-
work participation (Benevides et al., 2020). It is tics, the most frequently used occupational therapy
unclear from research literature the extent to which billable services, and the occupational therapy provider
occupational therapy is being delivered to people availability to support such services.
across the lifespan or what types of occupational ther- The purpose of this study was to describe occupa-
apy services are being delivered. tional therapy services for autistic people and those
Services in childhood are frequently supported with other developmental conditions across the life-
through educational systems, but services delivered span from across all 50 states and Washington, DC.
and billable through private insurance or Medicaid The following research questions were used:
waivers vary by coverage and age. Autistic individuals 1. Among Medicaid-insured autistic people and those
frequently require continued supports during the post- with other developmental disabilities, who is likely
secondary transition and adulthood period, but to receive occupational therapy services?
services tend to end for both medical and education 2. What are the procedure codes that occupational
settings after people transition out of school (Roux therapy providers bill for most frequently when
et al., 2013, 2020; Shattuck et al., 2012). Some people serving children and adults with diagnosis codes
may continue to be eligible for publicly available insur- for autism spectrum disorder (ASD), an intellec-
ance such as Medicaid or Medicare across the early tual disability (ID), or both?
adult transition period and through adulthood via dis- For Research Question 1, we hypothesized that
ability programs. Research has revealed a diverse occupational therapy service delivery would differ by
publicly insured autistic adult cohort who continue to age and co-occurring ID, which is frequently a marker
receive a variety of services across the lifespan (Benev- of increased functional needs (e.g., Buescher et al.,
ides et al., 2019; Schott et al., 2021; Shea et al., 2018, 2014). We had no expectations about the frequencies
2019; Turcotte et al., 2016). Occupational therapy of billed procedure codes, so we present no hypothesis
health services researchers have identified gaps in for Research Question 2.
health care outcomes that are amenable to interven-
tion (e.g., Gilmore et al., 2021; Hand et al., 2020); thus,
an opportunity has been created for researchers to
Method
understand and quantify occupational therapy service Design and Data Source
delivery patterns and gaps that could inform future We conducted a retrospective case–control cohort
practice and policy using large-scale data and popula- study of existing claims records to describe people
tion-based samples. receiving and not receiving occupational therapy serv-
Population-based evidence is needed to better ices. We used the Centers for Medicare and Medicaid
understand occupational therapy service delivery that Services (CMS) Medicaid Analytic eXtract (MAX) files
is occurring across the lifespan for autistic people and for the service years ranging from 2009 to 2012 that
those with related developmental conditions. Descrip- contained claims on beneficiaries with ASD, ID, or
tive cohort analyses can reveal patterns in billing and both. These files are research-identifiable claims
service delivery that suggest underlying trends that records with the ability to link beneficiary demo-
may require educational or policy changes; in addition, graphics from the Personal Summary File with claims
they may suggest opportunities for practice expansion. for health care services across outpatient, inpatient,
As some practice areas experience growth in patient long-term care, emergency, and acute care settings and
populations, our profession needs to be aware of the medication files. Analysis of these data for health serv-
demand and the supply of occupational therapy pro- ices research purposes underwent institutional review
viders; thus, educational programs should include board approval at Drexel University (Protocol
content related to developmental conditions in adult 1603004379); all analyses were conducted at Drexel Uni-
intervention courses, not just pediatric courses. Reim- versity. Protocol details can be furnished on request.
bursement policy and legislation that include age caps Claims records include diagnosis codes, Current
on waivers or funding caps on services delivered by Procedural Terminology ® (CPT ®) and Healthcare
professionals serving this population may need Common Procedure Coding System (HCPCS) proce-
research evidence to support advocacy efforts to dure codes, Medicaid Statistical Information System
improve service access. To better support occupational (MSIS) type of service codes, and CMS specialty codes,
hereafter referred to as “procedure codes,” “type of
1
We primarily use the identity-first term autistic individuals when service codes,” or “CMS provider specialty codes,”
referring to adults, which honors the lived experience and preferences respectively (American Medical Association, 2017;
of the autism community (Bury et al., 2020; Kenny et al., 2016). When
referring to children or people with other developmental conditions, Centers for Medicare & Medicaid Services, 2004; Cen-
we continue to use person-first language. ters for Medicare & Medicaid Services, 2012; ResDac,
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JANUARY/FEBRUARY 2022, VOLUME 76, NUMBER 1 2
n.d.). Type of service codes defines the service (e.g., more areas, each 15 min; therapeutic exercises to
“home health,” “physical therapy, occupational therapy, develop strength and endurance, range of motion and
speech and hearing services,” “outpatient hospital”), and flexibility”) and CPT 97535 (defined as “Self-care/
provider specialty codes define the provider who deliv- home management training, direct one-on-one con-
ered the claim service. CMS specialty codes were used tact, each 15 min”). The most frequently billed
to identify occupational therapy providers. occupational therapy procedure codes were identified
from the procedure code field available in the claim.
Sample Identification
We identified beneficiaries with either ASD (Interna- Data Analysis
tional Classification of Diseases–Ninth Revision–Clinical We provide frequencies and percentages of demo-
Modification [ICD–9–CM; Centers for Disease Control graphic characteristics of unique people receiving or
and Prevention, 2011] Code 299.xx) or ID (ICD–9– not receiving occupational therapy services by group
CM Codes 317–319.xx) as those with at least two out- (ASD only, ASD1ID, ID only) and by age (<18 yr,
patient claims or at least one inpatient claim with the 18–64 yr). Logistic regression was used to examine the
ICD–9–CM diagnosis code at any year. Three groups odds of receiving occupational therapy within each
were analyzed: ASD without ID (ASD only), ASD with group by demographic characteristic, and odds ratios
ID (ASD1ID), and ID without ASD (ID only). People and 95% confidence intervals were calculated, adjusted
with end-stage renal disease were excluded because on the other demographic characteristics. Frequency
they frequently require different types of care. A total of billing specific procedure codes is summarized
of 1,366,552 beneficiaries were included. We selected across the 4-yr period for each group. We report the
specific demographic and social characteristics that are 10 most frequent claim procedure codes billed by
frequently associated with service utilization and are occupational therapy providers, which captured
markers of disparities. Age was calculated at the first between 96% and 99% of all occupational therapy
observed month of enrollment. Gender and race–eth- claims for each group.
nicity were extracted from the MAX Personal
Summary File. We determined urbanicity by using zip Results
code and 2010 census urban and rural classification. Demographic characteristics are presented in Tables 1
We defined eligibility category using the most frequent (age <18 yr) and 2 (ages 18–64 yr); the results of logis-
MAX uniform eligibility codes.
tic regression predicting the odds of receiving
occupational therapy for each group (ASD only,
Identification of Occupational Therapy Services ASD1ID, ID only) by specific predictors are also
Any claims that met one of the following criteria were shown. A greater proportion of children with
flagged as “occupational therapy services”: (1) claims ASD1ID received occupational therapy (29.2%) than
in which the CMS provider specialty code of “67” did children with ASD only (24.2%) or ID only
(occupational therapist) was documented or (2) any (20.5%). Similarly, a greater proportion of adults with
claim from another type of service or group that may ASD1ID received occupational therapy (6.3%) than
bill on behalf of occupational therapy practitioners did adults with ASD only (3.7%) or ID only (4.7%).
(e.g., ambulatory health center) plus a CPT code that Several demographic predictors were associated
falls under the occupational therapy scope of practice. A with occupational therapy service receipt, including
list of the CPT procedure codes used for the purpose of age, gender, race–ethnicity, Medicaid reason for eligi-
this research can be obtained from the first author. bility (e.g., poverty), and urbanicity (see Tables 1 and 2,
“Predictors of Occupational Therapy Service Receipt”
column). Generally, among children and adolescents,
Types of Occupational Therapy Billed Services children and adolescents between ages 6 and 17 yr
Among available claims flagged as occupational ther-
were significantly less likely to have received occupa-
apy services, the procedure codes associated with those
tional therapy than children ages 0 to 5 yr across all
occupational therapy claims were summarized by fre-
groups. Among adults with ASD only, those between
quency. No selection process was used for procedure
ages 35 and 64 yr were significantly more likely than
codes. Examples of procedure codes include CPT
those ages 18 to 24 yr to receive occupational therapy.
971102 (defined as “Therapeutic procedure, one or
The opposite pattern was observed among adults with
2
Codes shown refer to CPT 2017 (American Medical Association,
ASD1ID and ID only; people 25 to 64 years old were
2017, CPT 2017 standard, Chicago: American Medical Association significantly less likely to receive occupational therapy
Press) and do not represent all of the possible codes that may be than those ages 18 to 24 yr.
used in occupational therapy evaluation and intervention. After
2017, refer to the current year’s CPT code book for available codes. The most frequently occurring occupational ther-
CPT codes are updated annually and become effective January 1. apy procedure codes by group and age (<18 yr, ≥18
CPT is a trademark of the American Medical Association. CPT five- yr) are presented in Table 3. The majority of children
digit codes, two-digit codes, modifiers, and descriptions are copy-
right © 2017 by the American Medical Association. All rights and adolescents, regardless of group, received thera-
reserved. peutic activities (CPT 97530) and therapeutic exercises
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JANUARY/FEBRUARY 2022, VOLUME 76, NUMBER 1 3
Table 1. Demographic Characteristics of Total Available Sample of Medicaid-Enrolled Children and Adolescents With ASD
or ID (Younger Than Age 18 yr) and Predictors of Occupational Therapy Service Receipt, 2009–2012 (N = 664,214)
Characteristic n (%) Predictors of Occupational Therapy Service
Receipt, OR [95% CI]a
ASD Only ASD+ID ID Only ASD Only ASD+ID ID Only
(n 5 351,361) (n 5 75,555) (n 5 237,298)
Received 84,891 (24.2) 22,091 (29.2) 48,650 (20.5) Outcome Outcome Outcomeb
occupational variable variable variable
therapy treatment
Age at enrollment, yr
0–5 (Ref.) 165,823 18,571 (24.6) 65,605 (27.6)
(47.2)
6–12 136,665 33,658 (44.5) 92,377 (38.9) 0.49 [0.48, 0.57 [0.54, 0.61 [0.60,
(38.9) 0.50]* 0.59]* 0.63]*
13–17 48,873 (13.9) 23,326 79,316 (33.4) 0.15 [0.15, 0.22 [0.21, 0.27 [0.26,
(30.9) 0.16]* 0.23]* 0.28]*
Sex
Male (Ref.) 277,232 56,798 (75.2) 139,860
(78.9) (58.9)
Female 74,073 (21.1) 18,755 97,424 (41.1) 0.95 [0.93, 1.05 [1.01, 1.03 [1.01,
(24.8) 0.97]* 1.09]* 1.05]*
Race–ethnicity
White (Ref.) 181,255 38,605 (51.1) 108,389
(51.6) (45.7)
Black 55,659 (15.8) 13,394 (17.7) 54,400 (22.9) 0.64 [0.63, 0.65 [0.62, 0.60 [0.58,
0.66]* 0.68]* 0.61]*
Asian/Pacific 7,425 (2.1) 2,507 (3.3) 7,102 (3.0) 0.60 [0.56, 0.48 [0.43, 0.52 [0.49,
Islander 0.63]* 0.53]* 0.56]*
Hispanic/Latino 61,820 (17.6) 10,231 (13.5) 36,295 (15.3) 0.88 [0.86, 0.67 [0.64, 0.71 [0.69,
0.90]* 0.71]* 0.73]*
Other 45,202 (12.9) 10,818 (14.3) 31,112 (13.1) 1.21 [1.18, 1.25 [1.19, 1.14 [1.11,
1.24]* 1.31]* 1.18]*
Urbanicity
Urban (Ref.) 248,210 53,418 (70.7) 161,029
(70.6) (67.9)
Suburban 30,840 (8.8) 6,724 (8.9) 23,531 (9.9) 1.01 [0.98, 1.04] 0.99 [0.94, 1.05] 0.85 [0.82,
0.88]*
Rural 63,439 (18.1) 13,250 (17.5) 47,490 (20.0) 0.90 [0.89, 0.99 [0.95, 1.03] 0.81 [0.79,
0.92]* 0.83]*
Missing 8,872 (2.5) 2,163 (2.9) 5,248 (2.2) 0.69 [0.65, 0.82 [0.74, 0.83 [0.77,
0.73]* 0.91]* 0.90]*
Eligibility category

(Continued)

(CPT 97110), with 76% to 79% of the pediatric sam- and billing practices for people with developmental
ples having claims with these procedure codes. conditions from large administrative claims samples
Therapeutic activities and therapeutic exercises also to determine patterns of service use to inform pol-
made up the majority of billed claims for adults with icy and practice initiatives. Within our large
ASD only (46%). Among adults with ASD1ID and ID Medicaid-enrolled sample of people with develop-
only, community/work reintegration (CPT 97537: mental conditions, we identified three main results
ASD1ID, 39%; ID only, 39%) was also frequently that affect occupational therapy service delivery.
billed. First, we found that occupational therapy service
delivery for unique age cohorts of Medicaid-insured
children and adolescents with ASD, ID, or both
Discussion decreases between ages 5 and 17 yr, which supports
People with developmental conditions, such as those earlier work suggesting that occupational therapy serv-
with ASD, ID, or both ASD and ID, tend to have spe- ices decline through adolescence (Cidav et al., 2013). A
cific needs that vary across the lifespan and that novel result is that rates of occupational therapy service
remain unmet (e.g., Schott et al., 2021). Lack of regular delivery remained low for all beneficiaries with devel-
and sustained supports across the transition-to-adult opmental disabilities in adulthood, with only
period is linked to poor adult health outcomes approximately 4% to 6% of eligible people with ASD
among people with developmental disabilities only, ASD1ID, or ID only having billed occupational
(Anderson et al., 2018; Cheak-Zamora & Teti, therapy services across the period ranging from 18 to
2015). The occupational therapy profession offers 64 yr. Less is known about the complexities of aging
skilled services to address many of the areas that with various developmental conditions; however, it is
are reported challenges. No studies to our knowl- clear that occupational therapy practitioners will need
edge have examined occupational therapy trends to develop knowledge in understanding how to support

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JANUARY/FEBRUARY 2022, VOLUME 76, NUMBER 1 4
Table 2. Demographic Characteristics of Total Available Sample of Medicaid-Enrolled Adults With ASD or ID (Ages 18–64 yr)
and Predictors of Occupational Therapy Service Receipt, 2009–2012 (N = 702,338)
Characteristic n (%) Predictors of Occupational Therapy Service Receipt, OR
[95% CI]a
ASD Only ASD+ID ID Only ASD Only ASD+ID ID Only
(n 5 45,650) (n 5 60,048) (n 5 596,640)
Received 1,686 (3.7) 3,782 (6.3) 27,931 (4.7) Outcome Outcome Outcomeb
occupational variable variable variable
therapy treatment
Age at enrollment, yr
18–24 (Ref.) 26,333 (57.7) 25,230 (42.0) 126,295
(21.2)
25–34 10,223 (22.4) 16,124 (26.9) 134,798 0.85 [0.75, 0.74 [0.69, 0.75 [0.72,
(22.6) 0.97]* 0.81]* 0.78]*
35–44 4,640 (10.2) 9,672 (16.1) 129,292 1.18 [1.01, 0.60 [0.54, 0.72 [0.69,
(21.7) 1.38]* 0.67]* 0.74]*
45–54 3,369 (7.4) 6,942 (11.6) 143,079 1.45 [1.23, 0.62 [0.56, 0.71 [0.69,
(24.0) 1.71]* 0.70]* 0.74]*
55–64 1,085 (2.4) 2,080 (3.5) 63,176 (10.6) 1.55 [1.19, 0.70 [0.58, 0.72 [0.69,
2.02]* 0.84]* 0.76]*
Sex
Male (Ref.) 33,660 (73.7) 43,136 (71.8) 321,450
(53.9)
Female 11,990 (26.3) 16,912 (28.2) 275,186 1.65 [1.49, 1.28 [1.20, 1.24 [1.21,
(46.1) 1.83]* 1.38]* 1.27]*
Race–ethnicity
White (Ref.) 30,196 (66.1) 38,169 (63.6) 387,777
(65.0)
Black 6,091 (13.3) 11,973 (19.9) 117,985 0.63 [0.53, 0.64 [0.58, 0.79 [0.76,
(19.8) 0.75]* 0.70]* 0.82]*
Asian/Pacific 1,031 (2.3) 1,620 (2.7) 12,435 (2.1) 0.70 [0.48, 1.03] 0.43 [0.33, 0.48 [0.43,
Islander 0.57]* 0.54]*
Hispanic/Latino 2,983 (6.5) 4,103 (6.8) 45,540 (7.6) 0.71 [0.57, 0.44 [0.37, 0.44 [0.41,
0.89]* 0.53]* 0.47]*
Other 5,349 (11.7) 4,183 (7.0) 32,903 (5.5) 1.14 [0.99, 1.32] 0.70 [0.61, 0.81 [0.77,
0.81]* 0.86]*
Urbanicity
Urban (Ref.) 32,898 (72.1) 43,851 (73.0) 409,748
(68.7)
Suburban 3,664 (8.0) 4,932 (8.2) 57,719 (9.7) 0.93 [0.78, 1.12] 0.87 [0.77, 0.87 [0.83,
0.99]* 0.91]*
Rural 8,194 (17.9) 9,623 (16.0) 115,186 0.97 [0.85, 1.10] 1.16 [1.06, 1.03 [1.00, 1.07]
(19.3) 1.26]*
Missing 894 (2.0) 1,642 (2.7) 13,987 (2.3) 0.69 [0.45, 1.05] 0.50 [0.38, 0.60 [0.54,
0.67]* 0.67]*

(Continued)
people with developmental conditions in their self- of occupational therapy service delivery, and a contin-
management of chronic conditions commonly associ- ued need exists for evaluation of factors that
ated with older adults. contribute to the understanding of systems that pro-
Second, we found that occupational therapy service mote racism (e.g., Johnson et al., 2021; Johnson &
receipt was predicted by other demographic character- Lavalley, 2021).
istics besides age; consistent across both children and Third, we found that the type of billed occupational
adults was that racial and ethnic minorities were sig- therapy service delivery codes differed for children and
nificantly less likely to receive occupational therapy. adults. Although therapeutic activities and therapeutic
Our study did not examine need-based reasons for exercises were commonly billed in pediatric and adult
treatment (e.g., care complexity or co-occurring condi- samples, billing codes that are uniquely occupational
tions); therefore, additional study is warranted to therapy focused were less frequently documented. For
obtain a nuanced understanding of predictors of occu- example, self-care/home management training (CPT
pational therapy service use. Racial and ethnic 97535) encompassing therapy activities related to
disparities in diagnosis, access to care, and service uti- ADLs and instrumental activities of daily living
lization have been well documented among autistic (IADLs) was infrequently billed in childhood, with
individuals (e.g., Durkin et al., 2017; Singh & Bunyak, between 5% and 8% of claims focused on this proce-
2019; Wiggins et al., 2020). Intersectional disparities in dure code. In contrast, this code was documented
access to care for people living in rural communities twice as frequently among adult claims. Although self-
and people with low income have also been part of the care is addressed in both childhood and adulthood,
national conversation on health outcomes (e.g., Cald- one possible explanation is that the increase in billing
well et al., 2016). Contributions of racism and systemic for this code in adulthood could be because of adults
barriers have not been solidly examined in the context seeking occupational therapy providers for services
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JANUARY/FEBRUARY 2022, VOLUME 76, NUMBER 1 5
Table 3. Most Frequently Used CPT ® Procedure Codes Among Occupational Therapy Claims for Medicaid-Enrolled
Children, Adolescents, and Adults With ASD, ASD+ID, and ID Only, 2009–2012
ASD-Only Claims ASD+ID Claims ID-Only Claims
a a
Procedure Code Frequency (%) Procedure Code Frequency (%) Procedure Codea Frequency (%)
Children and Adolescents (Total No. of Claims 5 8,346,801)
No. of Claims 5 4,392,615 No. of Claims 5 1,189,392 No. of Claims 5 2,764,794
97530 2,615,172 (60) 97530 621,580 (52) 97530 1,202,485 (43)
97110 855,159 (19) 97110 286,526 (24) 97110 1,004,560 (36)
97150 323,903 (7) 97150 110,526 (9) 97150 223,484 (8)
97535 257,237 (6) 97535 93,902 (8) 97535 135,207 (5)
97112 117,224 (3) 97112 25,682 (2) 97112 95,881 (3)
97533 71,184 (2) 97533 17,088 (1) 97003 25,182 (1)
97003 65,579 (1) 97003 13,633 (1) 97533 24,003 (1)
97004 33,994 (1) 97004 4,513 (0.38) 97140 17,435 (1)
97532 24,310 (1) 97532 4,435 (0.37) 97004 7,918 (0.29)
97140 8,612 (0.20) 97140 3,208 (0.27) 97113 7,830 (0.28)
Adults (Total No. of Claims 5 1,870,851)
No. of Claims 5 93,608 No. of Claims 5 289,344 No. of Claims 5 1,487,899
97537 26,764 (29) 97537 113,046 (39) 97537 586,579 (39)
97530 26,656 (28) 97535 94,639 (33) 97535 385,813 (26)
97110 17,120 (18) 97530 37,170 (13) 97110 243,939 (16)
97535 12,327 (13) 97110 27,941 (10) 97530 155,269 (10)
97150 2,615 (3) 97150 5,615 (2) 97112 23,652 (2)
97140 1,838 (2) 97112 2,121 (1) 97150 21,155 (1)
97112 1,642 (2) 97003 1,827 (1) 97140 16,580 (1)
97003 960 (1) 97533 1,686 (1) 97003 11,459 (1)
97532 899 (1) 97140 1,253 (0.43) 97533 7,027 (0.47)
97035 663 (1) 97004 827 (0.29) 97035 6,565 (0.44)

Note. Data source: 2009–2012 Medicaid Analytic eXtract files for all states. Claim frequency was identified as total claims with
that Current Procedural Terminology® (CPT®) code over the period 2009–2012, with percentage denominator being the total num-
ber of claims for that beneficiary group with an occupational therapy–related claim. ASD 5 autism spectrum disorder; ID 5
intellectual disability.
a
97003 5 occupational therapy evaluation code (pre-2017); 97004 5 occupational therapy reevaluation code (pre-2017);
97035 5 ultrasound, each 15 min; 97110 5 therapeutic exercises, each 15 min; 97112 5 neuromuscular reeducation of move-
ment, balance, coordination; 97113 5 aquatic therapy with therapeutic exercise; 97140 5 manual therapy techniques; 97150 5
therapeutic procedures, group; 97530 5 therapeutic activities, direct one-on-one, each 15 min; 97532 5 development of cogni-
tive skills to improve attention, memory, and problem solving; 97533 5 sensory integrative techniques to enhance sensory

related to home management (IADLs), something that practitioners typically treat under our scope of practice
is not typically addressed in childhood. (e.g., ADLs, IADLs, and occupations such as driving,
Possibly because the billing code encompasses two leisure, and employment; Eismann et al., 2017; Kirby
distinct occupations (ADLs and IADLs), it complicates et al., 2020; Orsmond et al., 2013; Stacey et al., 2019).
our understanding of the services that are being deliv- Several longitudinal studies of daily living skills have
ered. Daily living skills are an important predictor of shown declines or lack of improvement in these skills
life-course outcomes that transcend ID (Di Rezze in adulthood (Bal et al., 2015; Clarke et al., 2021;
et al., 2019), and addressing daily living skills beyond Smith et al., 2012).
childhood is essential for occupational therapy pro- Neuromuscular reeducation (CPT 97112) and sen-
viders to consider for both children and adults (Bal sory integration (CPT 97533) were also among the
et al., 2015; Boyd et al., 2014). Other research has least frequently billed CPT codes for pediatric clients.
found that autistic individuals lack supports for func- These results suggest that although much of the pedi-
tional, everyday activities that occupational therapy atric-focused occupational therapy literature describes

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JANUARY/FEBRUARY 2022, VOLUME 76, NUMBER 1 6
evidence related to sensory processing, sensory inte- variation in occupational therapy service use to begin
gration, and motor function for children with develop- to identify the impact of these policy differences.
mental disabilities (e.g., Kuhaneck et al., 2015; Watling
& Hauer, 2015), providers appear to be billing for
other procedure codes. Similarly, a great deal of litera- Implications for Occupational
ture details executive functioning challenges among Therapy Practice
autistic individuals (e.g., de Vries & Geurts, 2015), and Administrative claims records are useful for under-
the importance of compensatory cognitive strategies standing practice trends and important areas in which
and supports is emphasized for occupational therapy the occupational therapy profession is delivering care.
practitioners (e.g., Tomchek & Koenig, 2016). The results of this study have the following implica-
Our study demonstrated that very few claims tions for occupational therapy practice:
addressed cognitive skills and compensatory 䊏 Billing for pediatric occupational therapy serv-
approaches for cognition. Claims for this CPT code ices suggests a reliance on therapeutic activities
(97532) composed 1% of the ASD-only child and adult and exercises. To better support our occupa-
claims and <0.5% of the claims in the adult ASD1ID tional therapy scope of practice for children with
group. Practitioners should consider ways to promote developmental conditions and to distinguish
executive functioning as related to important occupa- ourselves from other professionals, we suggest
tions for people with developmental conditions such that providers clearly document the value of
as autism. Practice-related trends in billing could occupational therapy in delivering and billing
reflect coding preferences because of higher rates of for services aligned with important areas of
reimbursement for some codes versus others, fear of occupation, such as ADLs, IADLs, play, and
claim denial through use of some codes, or other pol- community participation.
icy guidance by state or institutions for billing. Future 䊏 Adults with developmental disabilities, includ-
research should explore these reasons to better under- ing autistic adults with or without ID, infre-
stand factors affecting occupational therapy’s ability to quently receive occupational therapy services.
demonstrate its unique value for clients. Practice-related guidance for promoting healthy
development of human occupation in these pop-
Limitations ulations is necessary, preferably developed in
Limitations to this study include the frequent criticisms collaboration with autistic people and those with
of administrative records: We could not definitively ID. For example, practice guidance should pro-
confirm diagnosis or delivery of occupational therapy vide evidence-based approaches for person–cen-
services. Because these claims are being processed with tered care models that promote quality of life,
the diagnostic codes associated with the groups improved mental health, and meaningful social
described, our results represent the groups as evaluated. and community participation. Educators should
Several claims were missing specific provider CMS spe- present developmental conditions and interven-
cialty code information to classify provider types. tions across the lifespan (not just in pediatric
Therefore, our estimates are likely an underestimate of courses).
occupational therapy services. We are confident that 䊏 Differences in service delivery exist by age,
services frequently billed by occupational therapy prac- race–ethnicity, and other demographic charac-
titioners and provided in settings in which teristics. Future research and policy efforts are
occupational therapists and occupational therapy assis- needed to better understand and address inter-
tants work were included. We acknowledge that other sectional factors contributing to occupational
providers may be working in settings similar to occu- therapy service delivery barriers. Structural,
pational therapists and billing for services that social, and economic incentives and disincen-
occupational therapists would bill for. tives driving provider actions and disparate
Finally, MAX files are reported by states, and one service access among people with intellectual
state (Idaho) did not report its claims in time for and developmental conditions require
inclusion in the 2012 data release; therefore, we are investigation.
missing some claims records from that state. Through
analyses of the location of billed occupational therapy
services, we found that billing for certain procedure Conclusion
codes may be occurring more frequently in some Billed procedure code patterns do not consistently
states versus others. More research is needed to disen- reflect the unique occupation focus that occupational
tangle state-specific billing practices that influence therapy providers deliver to people with developmen-
providers. State Medicaid policies and waiver pro- tal disabilities across the lifespan, including those on
grams may vary in terms of the occupational therapy the autism spectrum and those with ID. Disparities in
services that are covered, and service coverage can also occupational therapy service receipt warrant attention
vary within states by program. A critical next step for and more nuanced evaluation of complex intersec-
this research is to examine inter- and intrastate tional factors driving access and service use.
THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JANUARY/FEBRUARY 2022, VOLUME 76, NUMBER 1 7
Acknowledgments Centers for Medicare & Medicaid Services. (2012). HCPCS—General
information; [modified 2012 July 04; cited 2012 Oct 4]. https://www.
This research was supported in part by American
cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.htm
Occupational Therapy Foundation Health Services Cheak-Zamora, N. C., & Teti, M. (2015). “You think it’s hard now . . . It
Research Grant OTF2019HSR (awarded to Teal W. gets much harder for our children”: Youth with autism and their
Benevides). This work was also supported in part by caregiver’s perspectives of health care transition services. Autism, 19,
National Institutes of Health Grant R01MH117653 992–1001. https://doi.org/10.1177/1362361314558279
(awarded to Lindsay Shea) and Health Resources and Cidav, Z., Lawer, L., Marcus, S. C., & Mandell, D. S. (2013). Age-related
Services Administration (HRSA) Grant UJ2MC31073. variation in health service use and associated expenditures among
children with autism. Journal of Autism and Developmental
The information, content, and conclusions represent
Disorders, 43, 924–931. https://doi.org/10.1007/s10803-012-1637-2
the opinions of the authors and not necessarily those
Clarke, E. B., McCauley, J. B., & Lord, C. (2021). Post–high school daily
of the HRSA, the U.S. Department of Health and living skills in autism spectrum disorder. Journal of the American
Human Services, or the U.S. government. Academy of Child and Adolescent Psychiatry, 60, 978–985. https://doi.
org/10.1016/j.jaac.2020.11.008
de Vries, M., & Geurts, H. (2015). Influence of autism traits and
References executive functioning on quality of life in children with an autism
American Medical Association. (2017). CPT 2017 standard. American spectrum disorder. Journal of Autism and Developmental Disorders,
Medical Association Press. 45, 2734–2743. https://doi.org/10.1007/s10803-015-2438-1
American Occupational Therapy Association. (2020). Occupational Di Rezze, B., Duku, E., Szatmari, P., Volden, J., Georgiades, S.,
therapy practice framework: Domain and process (4th ed.). American Zwaigenbaum, L., . . . Waddell, C.; Pathways in ASD Study Team.
Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https:// (2019). Examining trajectories of daily living skills over the preschool
doi.org/10.5014/ajot.2020.74S2001 years for children with autism spectrum disorder. Journal of Autism
Anderson, K. A., Sosnowy, C., Kuo, A. A., & Shattuck, P. T. (2018). and Developmental Disorders, 49, 4390–4399. https://doi.org/10.1007/
Transition of individuals with autism to adulthood: A review of s10803-019-04150-6
qualitative studies. Pediatrics, 141(Suppl. 4), S318–S327. https://doi. Durkin, M. S., Maenner, M. J., Baio, J., Christensen, D., Daniels, J.,
org/10.1542/peds.2016-4300I Fitzgerald, R., . . . Yeargin-Allsopp, M. (2017). Autism spectrum
Bal, V. H., Kim, S.-H., Cheong, D., & Lord, C. (2015). Daily living skills disorder among US children (2002–2010): Socioeconomic, racial, and
in individuals with autism spectrum disorder from 2 to 21 years of ethnic disparities. American Journal of Public Health, 107, 1818–1826.
age. Autism, 19, 774–784. https://doi.org/10.1177/1362361315575840 https://doi.org/10.2105/AJPH.2017.304032
Benevides, T. W., Carretta, H. J., & Graves, K. Y. (2019). Case Eismann, M. M., Weisshaar, R., Capretta, C., Cleary, D. S., Kirby, A. V.,
identification and characterization of autistic young adults in 2010 & Persch, A. C. (2017). Characteristics of students receiving
Medicare fee-for-service claims. Autism in Adulthood, 1, 210–218. occupational therapy services in transition and factors related to
https://doi.org/10.1089/aut.2018.0036 postsecondary success. American Journal of Occupational Therapy,
Benevides, T. W., Shore, S. M., Palmer, K., Duncan, P., Plank, A., 71, 7103100010. https://doi.org/10.5014/ajot.2017.024927
Andresen, M. L., . . . Coughlin, S. S. (2020). Listening to the autistic Gilmore, D., Harris, L., Longo, A., & Hand, B. N. (2021). Health status of
voice: Mental health priorities to guide research and practice in Medicare-enrolled autistic older adults with and without co-
occurring intellectual disability: An analysis of inpatient and
autism from a stakeholder-driven project. Autism, 24, 822–833.
institutional outpatient medical claims. Autism, 25, 266–274. https://
https://doi.org/10.1177/1362361320908410
doi.org/10.1177/1362361320955109
Boyd, B. A., McCarty, C. H., & Sethi, C. (2014). Families of children with
Hand, B. N., Angell, A. M., Harris, L., & Carpenter, L. A. (2020).
autism: A synthesis of family routines literature. Journal of
Prevalence of physical and mental health conditions in Medicare-
Occupational Science, 21, 322–333. https://doi.org/10.1080/
enrolled, autistic older adults. Autism, 24, 755–764. https://doi.org/
14427591.2014.908816
10.1177/1362361319890793
Buescher, A. V., Cidav, Z., Knapp, M., & Mandell, D. S. (2014). Costs of
Johnson, K. R., Bogenschutz, M., & Peak, K. (2021). Propositions for
autism spectrum disorders in the United Kingdom and the United
race-based research in intellectual and developmental disabilities.
States. JAMA Pediatrics, 168, 721–728. https://doi.org/10.1001/
Inclusion, 9, 156–169. https://doi.org/10.1352/2326-6988-9.3.156
jamapediatrics.2014.210
Johnson, K. R., & Lavalley, R. (2021). From racialized think-pieces
Bury, S. M., Jellett, R., Spoor, J. R., & Hedley, D. (2020). “It defines who I
toward anti-racist praxis in our science, education, and practice.
am” or “It’s something I have”: What language do [autistic]
Journal of Occupational Science, 28, 404–409. https://doi.org/10.1080/
Australian adults [on the autism spectrum] prefer? Journal of Autism
14427591.2020.1847598
and Developmental Disorders. Advance online publication. https:// Kenny, L., Hattersley, C., Molins, B., Buckley, C., Povey, C., & Pellicano,
doi.org/10.1007/s10803-020-04425-3 E. (2016). Which terms should be used to describe autism?
Caldwell, J. T., Ford, C. L., Wallace, S. P., Wang, M. C., & Takahashi, Perspectives from the UK autism community. Autism, 20, 442–462.
L. M. (2016). Intersection of living in a rural versus urban area and https://doi.org/10.1177/1362361315588200
race/ethnicity in explaining access to health care in the United States. Kirby, A. V., Diener, M. L., Adkins, D. E., & Wright, C. (2020).
American Journal of Public Health, 106, 1463–1469. https://doi.org/ Transition preparation activities among families of youth on the
10.2105/AJPH.2016.303212 autism spectrum: Preliminary study using repeated assessments
Centers for Disease Control and Prevention. (2011). International across a school year. PLoS One, 15, e0231551. https://doi.org/10.1371/
classification of diseases, ninth revision, clinical modification journal.pone.0231551
(ICD–9–CM). http://www.cdc.gov/nchs/icd/icd9cm.htm Kuhaneck, H. M., Madonna, S., Novak, A., & Pearson, E. (2015).
Centers for Medicare & Medicaid Services. (2004). CMS specialty codes/ Effectiveness of interventions for children with autism spectrum
healthcare provider taxonomy crosswalk (Version 4.0). https://www. disorder and their parents: A systematic review of family outcomes.
cms.gov/Medicare/Provider-Enrollment-and-Certification/ American Journal of Occupational Therapy, 69, 6905180040. https://
MedicareProviderSupEnroll/downloads/taxonomy.pdf doi.org/10.5014/ajot.2015.017855

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JANUARY/FEBRUARY 2022, VOLUME 76, NUMBER 1 8
Orsmond, G. I., Shattuck, P. T., Cooper, B. P., Sterzing, P. R., & Academy of Child and Adolescent Psychiatry, 51, 622–631.
Anderson, K. A. (2013). Social participation among young adults https://doi.org/10.1016/j.jaac.2012.03.001
with an autism spectrum disorder. Journal of Autism and Stacey, T. L., Froude, E. H., Trollor, J., & Foley, K. R. (2019). Leisure
Developmental Disorders, 43, 2710–2719. https://doi.org/10.1007/ participation and satisfaction in autistic adults and neurotypical adults.
s10803-013-1833-8 Autism, 23, 993–1004. https://doi.org/10.1177/1362361318791275
ResDac. (n.d.). MAX other services files, data documentation. https:// Tomchek, S. D., & Koenig, K. P. (2016). Occupational therapy practice
resdac.org/cms-data/files/max-ot guidelines for children and adolescents with autism spectrum disorder.
Roux, A. M., Rast, J. E., & Shattuck, P. T. (2020). State-level variation in American Occupational Therapy Association.
vocational rehabilitation service use and related outcomes among Turcotte, P., Mathew, M., Shea, L. L., Brusilovskiy, E., & Nonnemacher,
transition-age youth on the autism spectrum. Journal of Autism and S. L. (2016). Service needs across the lifespan for individuals with
Developmental Disorders, 50, 2449–2461. https://doi.org/10.1007/ autism. Journal of Autism and Developmental Disorders, 46,
s10803-018-3793-5 2480–2489. https://doi.org/10.1007/s10803-016-2787-4
Roux, A. M., Shattuck, P. T., Cooper, B. P., Anderson, K. A., Wagner, M., Watling, R., & Hauer, S. (2015). Effectiveness of Ayres Sensory
& Narendorf, S. C. (2013). Postsecondary employment experiences Integration® and sensory-based interventions for people with
among young adults with an autism spectrum disorder. Journal of the autism spectrum disorder: A systematic review. American
American Academy of Child and Adolescent Psychiatry, 52, 931–939. Journal of Occupational Therapy, 69, 6905180030. https://doi.
https://doi.org/10.1016/j.jaac.2013.05.019 org/10.5014/ajot.2015.018051
Schott, W., Nonnemacher, S., & Shea, L. (2021). Service use and unmet Wiggins, L. D., Durkin, M., Esler, A., Lee, L. C., Zahorodny, W.,
needs among adults with autism awaiting home- and community- Rice, C., . . . Baio, J. (2020). Disparities in documented
based Medicaid services. Journal of Autism and Developmental diagnoses of autism spectrum disorder based on demographic,
Disorders, 51, 1188–1200. https://doi.org/10.1007/s10803-020-04593-2 individual, and service factors. Autism Research, 13, 464–473.
Shattuck, P. T., Roux, A. M., Hudson, L. E., Taylor, J. L., Maenner, M. J., https://doi.org/10.1002/aur.2255
& Trani, J. F. (2012). Services for adults with an autism spectrum
disorder. Canadian Journal of Psychiatry, 57, 284–291. https://doi.
org/10.1177/070674371205700503
Shea, L. L., Field, R., Xie, M., Marcus, S., Newschaffer, C., & Mandell, D.
(2019). Transition-age Medicaid coverage for adolescents with autism Teal W. Benevides, PhD, MS, OTR/L, is Associate Professor,
and adolescents with intellectual disability. American Journal on Department of Occupational Therapy, College of Allied Health
Intellectual and Developmental Disabilities, 124, 174–185. https://doi. Sciences, Augusta University, Augusta, GA; tbenevides@augusta.
org/10.1352/1944-7558-124.2.174 edu
Shea, L. L., Xie, M., Turcotte, P., Marcus, S., Field, R., Newschaffer,
Sha Tao, MPH, is Data Analyst, A.J. Drexel Autism Institute, Drexel
C., & Mandell, D. (2018). Brief report: Service use and
University, Philadelphia, PA.
associated expenditures among adolescents with autism
spectrum disorder transitioning to adulthood. Journal of Autism Alec Becker, MAS, is Data Analyst, A.J. Drexel Autism Institute,
and Developmental Disorders, 48, 3223–3227. https://doi.org/ Drexel University, Philadelphia, PA.
10.1007/s10803-018-3563-4
Singh, J. S., & Bunyak, G. (2019). Autism disparities: A systematic review Kate Verstreate, MPH, is Data Analyst, A.J. Drexel Autism Institute,
Drexel University, Philadelphia, PA.
and meta-ethnography of qualitative research. Qualitative Health
Research, 29, 796–808. https://doi.org/10.1177/1049732318808245
Lindsay Shea, DrPH, MS, is Associate Professor, A.J. Drexel Autism
Smith, L. E., Maenner, M. J., & Seltzer, M. M. (2012). Institute, Drexel University, Philadelphia, PA.
Developmental trajectories in adolescents and adults with
autism: The case of daily living skills. Journal of the American

THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY  JANUARY/FEBRUARY 2022, VOLUME 76, NUMBER 1 9