Document. Reason. Choose your billing.
Capture the session, review your SOAP note, then select CPT codes and units.
Teaching case code
- 1Capture & reason
- 2Organize & review
- 3Copy or export
Session source
Your observations and clinical reasoning.
Checking on-device dictation… · Use an institution-approved tool if pasting speech-to-text.
Microphone workaround: Click the transcript, then use Windows + H on Windows or your phone keyboard’s microphone. On Mac, use the configured Dictation shortcut. Use only a program-approved dictation service; keyboard dictation may process audio outside this page.
Student billing worksheet
Choose codes, document time, and calculate units yourself.
The note and AI never select codes or units here. Use your clinical reasoning and the code reference below.
Medicare Part B rules & code reference
This exercise uses Medicare’s aggregate rule for direct, one-to-one 15-minute therapy services: 0–7 minutes = 0 units; 8–22 = 1; 23–37 = 2; 38–52 = 3; 53–67 = 4. Continue in 15-minute ranges. Count full blocks for each service, then allocate remaining available units to the largest remainders; ties may have multiple valid answers.
97129/97130 share one duration and one allocation. 97550/97551 are separate: Medicare requires the full initial 30 minutes and full additional 15-minute blocks. Do not add caregiver time to the 15-minute pool. Enter family time only in the initial service’s minutes field.
Use actual skilled service time. Exclude rest, waiting, independent activity, and overlapping minutes. Student participation alone does not establish billable time; supervision and payer requirements still apply. Definitions are educational summaries, not complete CPT descriptors. The check does not validate medical necessity, code appropriateness, coverage, modifiers, edits, or payment. Other payers may use different rules.
CMS therapy coding and timed-unit examples · CMS caregiver time requirements · CMS caregiver training guidance
Keep the occupation in the note.
Connect what limits performance, your skilled intervention, and the occupation it supports. A smoother sentence is useful only when that connection is yours.
Your documentation draft
Review the source before accepting the wording.
Occupational therapy note
SIM- · Student practice draft
Functional Problem Statement:
[Performance deficit + skilled intervention + occupation]
Subjective:
[Client or caregiver perspective]
Objective:
[Observed context + intervention + purpose + response]
Assessment:
[Your interpretation of function and progress]
Clinical Necessity:
[Your rationale for continued skilled services]
Plan:
[Your next session and longer-term plan]