Don’t let billing codes replace clinical judgement

Since the introduction of the new NDIS support item codes on 1 July (nearly a whole month ago!!), I’ve noticed a recurring theme in conversations with OTs. Not frustration about the changes themselves, but uncertainty.

Questions like, “Is this telehealth or non face to face?” “If I’m speaking with a parent, does that count as direct support?” “What if I’m on the phone with a support coordinator?” “Will this be rejected if I use the wrong code?”

They’re all reasonable questions, and we’ve been having the same discussions in our own team and throughout our OT community on facebook. What concerns me, though, is that the conversation is starting to shift away from clinical reasoning and towards administrative compliance.

That’s a direction we need to be careful of ⚠️

Clinical reasoning should always come first

As Occupational Therapists, we make hundreds of clinical decisions every week. We assess risk, adapt interventions, decide who needs to be involved in care and collaborate with multidisciplinary teams because we know that coordinated care leads to better outcomes.

None of those decisions begin with a billing code.

They begin with one question...what does this participant need?

Only after we’ve answered that should we be asking ourselves how that service is billed. When the administrative process starts driving clinical decisions, we risk losing sight of why we became OTs in the first place.

Not everything fits neatly into a box

One of the biggest challenges with the new codes is that many real world situations simply don’t fit neatly into one category.

A case conference with multiple providers, a coaching session with a parent, a phone call with a support coordinator that becomes a therapeutic discussion, or a multidisciplinary meeting about a participant who cannot meaningfully engage in telehealth themselves. 

These aren’t unusual situations. They’re everyday Occupational Therapy.

Trying to reduce complex clinical interactions into rigid administrative categories is rarely straightforward. That’s why different experienced clinicians can sometimes arrive at different conclusions while still exercising sound clinical judgement.

The important question isn’t whether someone else would have selected the exact same code.

It’s whether you can clearly explain your reasoning.

Good documentation matters more than perfect certainty

One thing I’ve learnt over many years of practice is that good documentation is your best friend. If you can clearly describe what occurred, why it was clinically necessary and how it supported the participant’s goals, you’ve already done the most important part.

Of course, we should all make every effort to understand the pricing arrangements and apply them correctly. But we also need to recognise that there are situations where the guidance simply isn’t black and white. In those moments, your clinical reasoning becomes incredibly important.

Document it.

Stand behind it.

Continue to monitor updates as further guidance becomes available.

We need to keep developing our clinical identity

Many therapists have developed their entire careers within one funding system. That isn’t a criticism, it’s simply the reality of our profession today.

The challenge is that funding models can sometimes shape how we think about service delivery. Clinical practice, however, extends well beyond any one scheme.

Across hospitals, community health, rehabilitation and private practice, Occupational Therapists have always worked collaboratively with families, carers and multidisciplinary teams. We’ve always needed to use professional judgement to determine what intervention is clinically appropriate.

That experience helps provide perspective when funding rules change. It reminds us that billing systems are designed to support clinical work, not define it.

Confidence comes from understanding your reasoning

If you’ve found yourself second guessing every invoice over the past few weeks, you’re certainly not alone. The conversations I’ve had suggest many OTs are experiencing exactly the same uncertainty.

My encouragement is this: continue learning, stay across the updates, ask questions, and have professional discussions with your peers. Most importantly, keep strengthening your clinical reasoning.

Because while pricing arrangements will continue to change, strong clinical judgement remains one of the most valuable skills an OT can develop.

The codes may evolve, the paperwork may become more complicated, and the language may change again.

But our responsibility remains exactly the same.

To provide thoughtful, evidence informed Occupational Therapy that genuinely improves the lives of people with disability.

That’s where our focus should always begin and end.

Understanding funding rules and keeping up with policy changes is one thing.

Having the confidence to apply your clinical judgement and guide your clients through uncertainty is another.

That can be difficult when your inner critic starts questioning every decision. Or when imposter syndrome and self doubt begin to creep in.

If that resonates with you, I’d encourage you to check out Solid Self-Confidence for OT Success, an on demand workshop presented by psychotherapist Toni Knight.

Toni specialises in helping allied health professionals build confidence, overcome self doubt and thrive in the challenges of clinical practice.

This workshop explores practical strategies to build authentic self confidence, manage imposter syndrome and trust your professional judgement, and you’ll have access to the recording and slides for six months so you can work through it at your own pace.