|MP 8.03.03||Occupational Therapy|
|Original Policy Date
|Return to Medical Policy Index|
Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.
Occupational therapy (OT) is a form of rehabilitation therapy involving the treatment of neuromusculoskeletal and psychological dysfunction through the use of specific tasks or goal-directed activities designed to improve the functional performance of an individual.
Occupational therapy involves cognitive, perceptual, safety, and judgment evaluations and training. These services emphasize useful and purposeful activities to improve neuromusculoskeletal functions and to provide training in activities of daily living (ADL). Activities of daily living include: feeding, dressing, bathing, and other self-care activities. Other occupational therapy services include the design, fabrication, and use of orthoses, and guidance in the selection and use of adapted equipment.
Occupational therapy services are considered medically necessary when performed to treat the needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies, or prior therapeutic intervention.
Occupational therapy services must meet all of the following criteria:
- meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies, or prior therapeutic intervention;
- achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time;
- provide specific, effective, and reasonable treatment for the patient’s diagnosis and physical condition;
- be delivered by a qualified provider of occupational therapy services. A qualified provider is one who is licensed where required and performs within the scope of licensure;
- require the judgment, knowledge, and skills of a qualified provider of occupational therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient.
BlueCard/National Account Issues
Plans may wish to review their contract language on occupational therapy services to ensure that the contract language is consistent with the Plan’s medical policy on OT.
Prior authorization of occupational therapy services is recommended to facilitate claims processing based on a review of the written plan of care.
Many Plans have visit or dollar maximums for OT services, or these services may be provided as a separate contractual benefit.
Occupational therapists may provide work-related and educational services in many settings including, but not limited to, industrial and office environments, work-evaluation and work-hardening programs, sheltered work programs, and schools and other educational settings. Plans should consult their specific contract exclusions when presented with requests for vocational training and educational services. Plans that wish to cover vocational training or educational services should list these specifically along with any restrictions or requirements. Plans that wish to exclude coverage of vocational training or educational services should incorporate specific contract language for this purpose. Many contracts have exclusions for these services.
Inpatient benefits are considered not medically necessary if the hospital admission is solely for the purpose of receiving occupational therapy.
An occupational therapy session is defined as up to 1 hour of occupational therapy (treatment and/or evaluation) on any given day. These sessions may include services such as:
- basic activities of daily living and self-care training;
- higher level independent living skills instruction;
- functionally oriented upper extremity exercise programs;
- cognitive, perceptual, safety, and judgment evaluations and training;
- upper extremity orthotic and prosthetic programs; and
- training of the patient and family in home exercise programs.
Up to 10 occupational therapy sessions per year may be covered without prior authorization. All subsequent treatment is subject to individual consideration. Prior authorization is recommended to facilitate claims processing based on a review of the written plan of care.
Plan of Care
The plan of care should include:
- specific statements of long- and short-term goals;
- measurable objectives;
- a reasonable estimate of when the goals will be reached;
- the specific treatment techniques and/or activities to be used in treatment; and
- the frequency and duration of treatment.
The plan of care should be updated as the patient’s condition changes and should be recertified by a physician at least every 30 days.
Duplicate therapy is considered not medically necessary. When patients receive both occupational and physical or speech therapy, the therapies should provide different treatments and not duplicate the same treatment. They must also have separate treatment plans and goals.
Certain types of treatment do not generally require the skills of a qualified provider of OT services and are therefore not medically necessary.
Service may include:
- passive range of motion (ROM) treatment, which is not related to restoration of a specific loss of function;
- services that maintain function by using routine, repetitive, and reinforced procedures, e.g., daily feeding programs once the adaptive procedures are in place;
Benefits should be denied for these services.
A maintenance therapy program consists of activities that preserve the patient’s present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved or when no further functional progress is apparent or expected to occur.
Benefits for the maintenance program itself, are not covered.
A search of literature was completed through the MEDLINE database for the period of January 1987 through October 26, 1995. The search strategy focused on references containing the following Medical Subject Heading:
- Occupational Therapy (including review or clinical trial or practice guidelines or meta-analysis)
Research was limited to English-language journals on humans.
|CPT||97003||Occupational therapy evaluation|
|97004||Occupational therapy re-evaluation|
|97535||Self-care/home management training (e.g., activities of daily living and compensation training, meal preparation, safety procedures and instructions in use of assistive technology devices/adaptive equipment) direct-one-on one contact by provider, each 15 minutes|
|ICD-9 Procedure||93.83||Occupational therapy|
|ICD-9 Diagnosis||Code applicable conditions|
|HCPCS||G0152||Services of occupational therapist in home health setting; each 15 minutes|
|S9129||Occupational therapy, in the home, per diem|
|Type of Service||Medical|
|Place of Service||Inpatient
Occupational Therapist’s office
|7/31/96||Add to Therapy section||New policy|
|4/15/02||Replace policy||Policy reviewed without literature review; new review date only|
|11/9/04||Replace policy||Policy reviewed by consensus; no further review scheduled. Coding updated.|