Billing is the part of independent practice that surprises therapists most — not because it's impossible, but because nobody taught it in graduate school.
In EI, schools, or a clinic, billing happens somewhere else. Claims go out. Payments come in. You document and keep moving. When you go independent, that invisible infrastructure becomes your responsibility. Understanding how it actually works before you see your first patient prevents the most common and expensive mistakes new independent therapists make.
How the insurance billing cycle actually works
When you see an insured patient, the flow is: you provide a service, you document it, you submit a claim to the insurance company with the right codes, the insurance company adjudicates the claim and pays you (or denies it with a reason), and you receive an explanation of benefits (EOB) or electronic remittance advice (ERA) that tells you what was paid, what was adjusted, what the patient owes, and why.
A claim includes six core pieces of information: the patient's insurance information (member ID, group number), your NPI and billing information, the date of service, the CPT code for the service you provided, the ICD-10 diagnosis code that supports medical necessity, and your charge amount.
Electronic claims typically pay in 14-30 days. Paper claims take longer. Claims requiring additional information or with errors go to a "pended" status that can delay payment significantly.
CPT codes for pediatric therapy — what you'll actually use
Speech-Language Pathology
- 92507 — Treatment of speech, language, voice, communication, and/or auditory processing disorder (individual). This is the workhorse SLP treatment code for the vast majority of pediatric sessions.
- 92508 — Treatment of speech, language, voice, communication, and/or auditory processing disorder (group, 2+ individuals).
- 92521 — Evaluation of speech fluency (e.g., stuttering)
- 92522 — Evaluation of speech sound production
- 92523 — Evaluation of speech sound production with evaluation and report of language comprehension and expression
- 92524 — Behavioral and qualitative analysis of voice and resonance
- 92610 — Evaluation of oral and pharyngeal swallowing function (for feeding evaluations)
Occupational Therapy
- 97165 — OT evaluation, low complexity (typically initial evaluations with straightforward presentation)
- 97166 — OT evaluation, moderate complexity (most typical pediatric OT evaluations)
- 97167 — OT evaluation, high complexity (complex presentations with multiple areas of deficit)
- 97168 — OT re-evaluation
- 97530 — Therapeutic activities (the primary OT treatment code for most pediatric sessions — dynamic activities directed to improve functional performance)
- 97533 — Sensory integration techniques (important distinction from 97530 — specifically for sensory integration intervention)
- 97110 — Therapeutic exercises (more specific to strengthening and exercise-based interventions)
Physical Therapy
- 97161 — PT evaluation, low complexity
- 97162 — PT evaluation, moderate complexity
- 97163 — PT evaluation, high complexity
- 97164 — PT re-evaluation
- 97530 — Therapeutic activities (shared with OT)
- 97110 — Therapeutic exercises
- 97112 — Neuromuscular reeducation
Always verify that the codes you're using are covered under the patient's specific plan and that you have authorization if the payer requires it. Coverage varies by payer, plan, and geographic market.
ICD-10 diagnosis codes and medical necessity
Every claim requires an ICD-10 diagnosis code that establishes medical necessity — why this child needs this service. The diagnosis on your claim must match your clinical documentation. Mismatches between your documented diagnosis and your claim diagnosis are a common audit trigger and denial reason.
Common ICD-10 codes in pediatric therapy:
- F80.0 — Phonological disorder (speech sound disorder)
- F80.1 — Expressive language disorder
- F80.2 — Mixed receptive-expressive language disorder
- F80.82 — Social (pragmatic) communication disorder
- F80.89 — Other developmental disorders of speech and language
- F82 — Specific developmental disorder of motor function
- F84.0 — Autism spectrum disorder
- F88 — Other disorders of psychological development
- F90.0–F90.9 — ADHD and related disorders
- R62.50 — Unspecified lack of expected normal physiological development (often used for general developmental delay)
The claim submission process in practice
Claims are submitted electronically through a clearinghouse — a service that routes claims to the correct payer. Most EMRs have clearinghouse integration built in (typically through Availity, Change Healthcare, or Office Ally). When you submit a claim through your EMR, it routes through the clearinghouse to the payer automatically.
After submission, you receive an ERA or EOB within 14-30 days for most payers. The ERA tells you: the amount paid, any adjustments (the difference between your charge and the payer's allowed amount), the patient responsibility (their copay, deductible, or coinsurance), and any denial codes with explanations.
Review your ERA regularly. Paid claims require payment posting. Denied claims require action — either resubmission with corrections or a formal appeal.
Denials: what happens and what to do
Claims get denied. It happens to every practice, and it doesn't mean you've done something wrong. Most denials are fixable. The key is responding quickly — payers have timely filing windows for appeals (often 60-90 days from the denial), and missing that window can forfeit your right to collect.
Common denial reasons and what they mean:
- Missing or invalid information (Claim errors): Wrong NPI, incorrect insurance ID, missing required modifier, incorrect date of birth. Fix the error and resubmit.
- Not medically necessary: Your documentation didn't establish that skilled therapy was required. Strengthen your documentation and submit an appeal with supporting clinical notes.
- Service not covered: This specific service isn't covered under the patient's plan. Bill the patient directly if you have a financial responsibility agreement, or write it off.
- Authorization required: You billed without obtaining required prior authorization. Obtain authorization retroactively if possible and resubmit, or appeal with documentation of medical necessity.
- Duplicate claim: You submitted this claim more than once. Confirm the original claim's status and void the duplicate.
- Timely filing exceeded: You submitted outside the payer's filing window (typically 90-365 days from date of service). Submit promptly to avoid this entirely — it's almost never recoverable once the window passes.
What billing actually costs in time
For a full caseload of 20-25 patients per week, expect 3-5 hours per week on billing at steady state: claim submission (30-60 min/week), ERA review and payment posting (30-60 min/week), denial follow-up and appeals (variable, often 1-2 hours/week), and patient balance communications (15-30 min/week). In the first 6 months, expect more — typically 5-8 hours/week while you're learning payer-specific patterns.
For independent therapists who don't want to manage this, two options exist: hire a medical billing service (typically 6-10% of collections) or join a platform like Coral Care where billing is handled entirely through our infrastructure. See our post on whether to hire a biller or do billing yourself for the full decision framework.
Coral Care handles all of this for our providers
Coral Care providers don't submit claims, manage denials, or post payments. Billing runs through Coral Care's infrastructure — you document the session in CoralPro, and our billing team handles the rest. For therapists who want to focus on clinical work rather than revenue cycle management, this is one of the most concrete operational advantages of the Coral Care model. Learn more about how billing works for Coral Care providers.
Frequently Asked Questions
Do I need prior authorization before every session?
It depends on the payer and the specific plan. Some plans require prior auth for evaluations only. Some require it for ongoing treatment beyond a certain number of sessions. Some require neither. You need to verify benefits and authorization requirements for each patient before the first session. Coral Care does this for every patient in our network.
What's the difference between a superbill and a claim?
A superbill is a detailed receipt you provide to a patient so they can submit a claim to their insurance themselves for out-of-network reimbursement. A claim is submitted directly by you (or your biller) to the insurance company. Out-of-network patients who want to use their benefits need a superbill; in-network patients don't.
How long does it take to get paid?
Most payers pay clean electronic claims in 14-30 days. Denials that require resubmission can extend the cycle to 60-90 days or longer. Consistent, clean claim submission and prompt denial follow-up are the most reliable ways to keep the payment cycle predictable.
