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SPD is also known as Sensory Integration Dysfunction

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Questions to Ask Your Insurance Company About Occupational Therapy
for Sensory Processing Disorder

SPD Diagnostic Codes

Occupational Therapists work with children who have Sensory Processing Disorder and who have co-existing diagnoses so they may bill for their services by the other diagnoses.

Many Occupation Therapists are able to give parents claim forms for Occupational Therapy services. Sensory Integration therapy is one of the things that can provided to the child under an OT's license along with the ability to give insurance claim forms to patients. The child must be billed with a diagnosis other than Sensory Processing Disorder or Autism.

Read more About Insurance Questions for Occupational Therapy.

About Insurance Codes For Sensory Processing Disorder

Updated 2016: We recommend that families get a "formal" referral from an MD, since Occupation Therapy is processed through the medical part of your insurance.  The current medical diagnoses would be from the ICD-10 (10th edition of the International Classification of Diseases.

In the absence of another diagnosis (such as autism F84.0, ADHD F90.0-90.9 depending on the type, etc.), some doctors are willing to use some of the following:

  • M62.81      Muscle Weakness (Generalized)
  • G70.2        Congenital and/or Developmental Myasthenia  
    or
  • F82           Specific Developmental Disorder of Motor Function

If the child has adequate coordination but has suspected sensory issues, some physicians use the diagnosis

  • F93.9        Childhood Emotional Disorder, Unspecified  or
  • G96.9        Disorder of Central Nervous System, Unspecified

and for some:

  • R63.3        Feeding Difficulties, Oral Aversion
  • F50.9        Eating Disorder, Unspecified

Other Questions To Ask Your Insurance Provider About Sensory Processing Disorder Coverage

  1. Does my insurance plan cover Occupational Therapy?
     
  2. Do I have to get a letter from a licensed medical provider (Physician or Physician’s Assistant) to state this is medically necessary?
     
  3. Do I need to send the letter from the medical provider before seeing the Occupational Therapy provider OR can it be submitted with the first bill?
     
  4. Is a diagnostic code required for reimbursement?
     
  5. What is the reimbursement scale for Occupational Therapy?
     
  6. What is the deductible on the plan? $__________ (amount)
     
  7. Is there any deductible left to meet this year?
    $__________ (amount)
     
  8. What is my co-payment per visit? $__________ (amount)
     
  9. Is there a limit on the total amount that can be paid out each year? $__________ (amount)
     
  10. Is an Occupational Therapy Evaluation covered by my insurance? $__________(amount)
     
  11. How many Occupational Therapy sessions will be covered by insurance in total per year?     $__________(amount)
     
  12. Does my coverage extend to the services of a non-network provider?
     
  13. What is the maximum covered cost per Occupational Therapy session?    $__________(amount)
     
  14. What is the Co-payment per Occupational Therapy session?  
    $__________(amount)
     
  15. Must we be referred for Occupational Therapy by a medical doctor or is an OTR sufficient?
     
  16. If we are already in Occupational Therapy with another provider, what is my remaining coverage for Occupational Therapy this year? $__________(amount)
     

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AIT Institute for Auditory Integration Training

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