How are ICD-11 and CPT codes used in occupational therapy?

• A. They are added to the Plan of Care to document the need for and provision of OT services.
• B. They are used to track staff attendance.
• C. They replace narrative notes entirely.
• D. They have no role in documentation.

Answer: (A)

Understanding why OT services are needed and what is delivered relies on good documentation and coding. ICD-11 codes capture the child’s medical diagnosis or condition that justifies OT, while CPT codes describe the actual OT procedures and sessions provided. Including these codes in the Plan of Care makes the justification clear and shows exactly what services will be or have been offered. This supports reimbursement, compliance, and data tracking, helping to demonstrate medical necessity and service effectiveness. Narrative notes still describe goals, progress, and clinical reasoning, but the codes provide a standardized way to summarize the who, why, and what of the care. They aren’t used for staff attendance and they don’t replace narrative documentation. For example, a plan might list the ICD-11 diagnosis driving OT needs and the CPT codes corresponding to evaluation and therapy sessions to be delivered.