Clinical UM Guideline

 

Subject: Occupational Therapy
Guideline #:  CG-REHAB-05 Publish Date:    12/27/2017
Status: Revised Last Review Date:    02/02/2017

Description

This document addresses occupational therapy (OT) services, skilled services which may be delivered by an occupational therapist or other health care professional acting within the scope of a professional license. OT is used for both rehabilitation and habilitation.

Rehabilitative services are intended to improve, adapt or restore functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality involving goals an individual can reach in a reasonable period of time. Benefits will end when treatment is no longer medically necessary and the individual stops progressing toward those goals.

Habilitative services are intended to maintain, develop or improve skills needed to perform activities of daily living (ADLs) or instrumental activities of daily living (IADLs) (see definitions) which have not (but normally would have) developed or which are at risk of being lost as a result of illness, injury, loss of a body part, or congenital abnormality. Examples include therapy for a child who is not walking at the expected age.

Note: The availability of rehabilitative and/or habilitative benefits for these services, state and federal mandates, and regulatory requirements should be verified prior to application of criteria listed below. Benefit plans may include a maximum allowable occupational therapy benefit, either in duration of treatment or in number of visits. When the maximum allowable benefit is exhausted, coverage will no longer be provided even if the medical necessity criteria described below are met.

Note: Please see the following related document for additional information:

Clinical Indications

Rehabilitative Services

Medically Necessary:

Rehabilitative occupational therapy (OT) services are considered medically necessary when ALL the following criteria are met:

  1. The therapy is aimed at improving, adapting or restoring functions which have been impaired or permanently lost as a result of illness*, injury, loss of a body part, or congenital abnormality; and
  2. The therapy is for conditions that require the unique knowledge, skills, and judgment of the occupational therapist for education and training that is part of an active skilled plan of treatment; and
  3. There is an expectation that the therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time; and
    1. An individual's function could not reasonably be expected to improve as the individual gradually resumes normal activities; and
    2. An individual's expected restoration potential would be significant in relation to the extent and duration of the therapy service required to achieve such potential; and
    3. The therapy documentation objectively verifies progressive functional improvement over specific time frames; and
  4. The services are delivered by a qualified provider of occupational therapy services (see definition); and
  5. The services 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 medical condition of the individual.

*Note: Illness includes a wide range of conditions. For purposes of clarity, illness includes, but is not limited to autism spectrum disorder.

Not Medically Necessary:

Maintenance (see definitions) therapy is considered not medically necessary as a rehabilitative service.

Rehabilitative OT services are considered not medically necessary if any of the following is determined:

  1. The therapy is not aimed at improving, adapting or restoring functions, which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality.
  2. The therapy is for conditions for which therapy would be considered routine educationally-based (that is, via school systems) or involved routine education, training, conditioning, or fitness . This includes treatments or activities that require only routine supervision.
  3. The expectation does not exist that the therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time.
    1. If function could reasonably be expected to improve as the individual gradually resumes normal activities, then the therapy is considered not medically necessary.
    2. If an individual's expected restoration potential would be insignificant in relation to the extent and duration of the therapy service required to achieve such potential, the therapy would be considered not medically necessary.
    3. The therapy documentation fails to objectively verify functional progress over a reasonable period of time.
  4. The physical modalities are not preparatory to other skilled treatment procedures.
  5. Treatments that do not generally require the skills of a qualified provider of OT services are considered not medically necessary. Examples include general range of motion or exercise programs, maintenance therapy, repetitive activities that an individual can self-practice independently or with a caregiver, swimming and routine water aerobics programs, and general public education/instruction sessions.
  6. Routine reevaluations not meeting the above criteria.
  7. Treatments that are not supported in peer-reviewed literature.

Duplicate rehabilitative therapy is considered not medically necessary. When individuals receive physical, occupational, or speech therapy, the therapists should provide different treatments that reflect each therapy discipline's unique perspective on the individual's impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals.

Habilitative Services

Medically Necessary:

Habilitative OT services are considered medically necessary when ALL the following criteria are met:

  1. The therapy is intended to maintain or develop skills needed to perform ADLs or IADLs which , as a result of illness*, injury, loss of a body part, or congenital abnormality , either :
    1. have not (but normally would have) developed; or
    2. are at risk of being lost; and
  2. The services are evidence-based and require the judgment, knowledge, and skills of a qualified provider of occupational therapy services due to the complexity of the therapy and the medical condition of the individual; and
  3. There is the expectation that the therapy will assist development of normal function or maintain a normal level of function; and
  4. There is a written treatment plan documenting the short-and long-term goal(s) of treatment, frequency and duration of treatment (including an estimate of when the goals will be met), and what quantitative measures will be used to assess objectively the level of functioning; and
  5. An individual would either not be expected to develop the function or would be expected to permanently lose the function (not merely experience fluctuation in the function) without the habilitative service; if the undeveloped or impaired function is not the result of a loss of body part or injury, a physician experienced in the evaluation and management of the undeveloped or impaired function has confirmed that the function would either not be expected to develop or would be permanently lost without the habilitative service and concurs that the written treatment plan is likely to result in meaningful development of the function or prevention of loss of the function; and
  6. The therapy documentation objectively verifies that, at a minimum, functional status is developed or maintained; and
  7. The services are delivered by a qualified provider of occupational therapy services (see definition).

*Note: Illness includes a wide range of conditions. For purposes of clarity, illness includes, but is not limited to, autism spectrum disorder or developmental delay.

Not Medically Necessary:

Habilitative OT services are considered not medically necessary if any of the following is determined:

  1. The therapy is not aimed at developing or maintaining functions, which would normally develop.
  2. The therapy is aimed at a function which would be permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality whether or not therapy was provided.
  3. The therapy is for conditions for which therapy would be considered routine educational, training, conditioning, or fitness. This includes treatments or activities that require only routine supervision.
  4. The expectation does not exist that the therapy will result in developing or maintaining the expected level of functioning within a reasonable and predictable period of time.
  5. The therapy documentation fails to objectively verify functional status is, at a minimum, maintained.
  6. The physical modalities are not preparatory to other skilled treatment procedures.
  7. Treatments that do not generally require the skills of a qualified provider of OT services are considered not medically necessary. Examples include general range of motion or exercise programs, maintenance therapy, repetitive activities that an individual can self-practice independently or with a caregiver, swimming and routine water aerobics programs, and general public education/instruction sessions.
  8. Routine reevaluations not meeting the above criteria.
  9. Treatments that are not supported in peer-reviewed literature.

Duplicate habilitative therapy is considered not medically necessary. When individuals receive physical, occupational, or speech therapy, the therapists should provide different treatments that reflect each therapy discipline's unique perspective on the individual's impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals.

Documentation

Evaluation
A comprehensive evaluation is essential to determine if OT services are medically necessary, gather baseline data, establish a treatment plan, and develop goals based on the data. The initial evaluation is usually completed in a single session. An evaluation is needed before implementing any OT treatment. Evaluation begins with the administration of appropriate and relevant assessments using standardized assessments and tools. The evaluation must include:

Treatment Sessions
An occupational therapy session can vary from fifteen minutes to four hours per day; however, treatment sessions lasting more than one hour per day are rare in outpatient settings. Treatment sessions for more than one hour per day may be medically appropriate for inpatient acute settings, day treatment programs, and select outpatient conditions, but must be supported in the treatment plan and based on an individual's medical condition. These sessions may include:

Documentation of treatment sessions must include:

Progress Reports
In order to reflect that continued OT services are medically necessary, intermittent progress reports must demonstrate that the individual is making functional progress. Progress reports should include at a minimum:

Reevaluation
A reevaluation is usually indicated when there are new significant clinical findings, a rapid change in individual's status, or failure to respond to occupational therapy interventions. There are several routine reassessments that are not considered reevaluations. These include ongoing reassessments that are part of each skilled treatment session, progress reports, and discharge summaries.

Reevaluation is a more comprehensive assessment that includes all the components of the initial evaluation, such as:

Providers of OT Services

The services are delivered by a qualified provider of occupational therapy services who is certified, licensed, or otherwise regulated by the State or Federal governments. Occupational therapy assistants may provide services under the direction and supervision of an occupational therapist. Benefits for services provided by these practitioners are dependent upon the member's contract language.

Aides, athletic trainers, exercise physiologists, life skills trainers, and rehabilitation technicians do not meet the definition of a qualified practitioner regardless of the level of supervision. Aides and other nonqualified personnel as listed above are limited to non-skilled services such as preparing the individual, treatment area, equipment, or supplies; assisting a qualified therapist or assistant; and transporting individuals. They may not provide any direct member treatments, modalities, or procedures.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

92605

Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour

92618

Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes

92606

Therapeutic service(s) for the use of non-speech-generating device, including programming and modification

92607-92608

Evaluation for prescription for speech-generating augmentative and alternative communication device

92609

Therapeutic services for the use of speech-generating device, including programming and modification

92610

Evaluation of oral and pharyngeal swallowing function

92611

Motion fluoroscopic evaluation of swallowing function by cine or video recording

94667

Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation

94668

Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent

97010-97028

Application of a modality to one or more areas (supervised) [includes codes 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028]

97032-97036

Application of a modality to one or more areas (constant attendance) [includes codes 97032, 97033, 97034, 97035, 97036]

97039

Unlisted modality [when not specified as a procedure that is considered investigational and not medically necessary]

97110-97124

Therapeutic procedure, one or more areas [includes codes 97110, 97112, 97113, 97116, 97124]

97127

Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact

97139

Unlisted therapeutic procedure (specify)

97140

Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes

97150

Therapeutic procedure(s), group  (2 or more individuals)

97165-97167

Occupational therapy evaluation [includes codes 97165, 97166, 97167]

97168

Re-evaluation of occupational therapy established plan of care

97530

Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes

97533

Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes

97535

Self care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes

97537

Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment) direct one-on-one contact, each 15 minutes

97542

Wheelchair management (eg, assessment, fitting, training), each 15 minutes

97545-97546

Work hardening/conditioning

97597-97598

Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session

97602

Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session

97750

Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes

97755

Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes

97760

Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes

97761

Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes

97763

Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes

97799

Unlisted physical medicine/rehabilitation service or procedure [when not specified as a procedure that is considered investigational and not medically necessary]

 

 

HCPCS

 

G0129

Occupational therapy requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per session (45 minutes or more)

G0152

Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes

G0158

Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes

G0160

Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes

G0281

Electrical stimulation, (unattended), to one or more areas, for chronic Stage III and Stage IV pressure ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care

G0282

Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281

G0283

Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care

G0295

Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses

G0329

Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, and diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care

G0515

Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

S8950

Complex lymphedema therapy, each 15 minutes

S8990

Physical or manipulative therapy performed for maintenance rather than restoration

S9129

Occupational therapy, in the home, per diem

 

 

 

Note: the following CPT informational modifiers may be used with the above procedure codes:

96

Habilitative Services

97

Rehabilitative Services

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Definitions

Activities of daily living (ADLs): Self-care activities such as transfers, toileting, grooming and hygiene, dressing, bathing, and eating.

Developmental delay: A condition that occurs when a child is not developing or achieving skills by the expected time frame. Developmental delay can occur in one or many areas -for example, thinking (cognitive), gross or fine motor, language or social skills (American Academy of Pediatrics, 2006).

Instrumental activities of daily living (IADLs): Activities related to independent living and include preparing meals, managing money, shopping, doing housework and using a telephone; IADLs do not involve personal care activities.

Maintenance treatments: Services intended to preserve the individual's present level range, strength, coordination, balance, pain, activity, function, etc. and prevent regression of the same parameters. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur.

Qualified provider of occupational therapy services: One who is licensed where required and performs within the scope of licensure.

References

Peer Reviewed Publications:

  1. Legg LA, Drummond AE, Langhorne P. Occupational therapy for patients with problems in activities of daily living after stroke. Cochrane Database Syst Rev. 2006;(4):CD003585.
  2. Moyers PA. The guide to occupational therapy practice. American Occupational Therapy Association. Am J Occup Ther. 1999; 53(3):247-322.
  3. Reitz SM, Austin DJ, Brandt LC, et al. Guidelines to the Occupational Therapy Code of Ethics. Am J Occup Ther. 2006; 60(6):652-668.
  4. Steultjens EM, Dekker JJ, Bouter LM, et al. Evidence of the efficacy of occupational therapy in different conditions: an overview of systematic reviews. Clin Rehabil. 2005; 19(3):247-254.
  5. Steultjens EM, Dekker JJ, Bouter LM, et al. Occupational therapy for rheumatoid arthritis. Cochrane Database of Syst Rev. 2004;(1):CD003114.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Pediatrics. Council on Children with Disabilities; Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee; Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006; 118(1):405-420.
  2. American Occupational Therapy Association. Guidelines for supervision, roles, and responsibilities during the delivery of occupational therapy services. Am J Occup Therapy. 2004; 58(6):663-667.
  3. Centers for Medicare & Medicaid Services (CMS). Pub. 100-02, Chapter 15, Section 220. Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance and Section 230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology. September 3, 2014. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed on December 19, 2016.
  4. Centers for Medicare & Medicaid Services. Manuals. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Index.html . Accessed on December 19, 2016.
    • Home Health Agency Manual. Pub. 11. Chapter 2, Section 205.2. Coverage of Services Which Establish Home Health Eligibility. Skilled Therapy Services. Last updated May 11, 2015.
    • Hospital Manual. Pub.10. Chapter 2, Section 210.9. Coverage of Hospital Services. Occupational Therapy Furnished by the Hospital or by Others Under Arrangements With the Hospital and Under its Supervision. Last updated September 8, 2005.
    • Outpatient Physical Therapy Comprehensive Outpatient Rehabilitation Facility and Community Mental Health Center Manual. Pub. 9. Chapter 2, Coverage of Services and Chapter 5, Section 503. Intermediary Medical Review for Part B Outpatient. Occupational Therapy (OT). Last updated September 8, 2005.
  5. Centers for Disease Control and Prevention. Developmental monitoring and screening for health professionals. February 23, 2016. Available at: http://www.cdc.gov/ncbddd/childdevelopment/screening-hcp.html. Accessed on December 19, 2016.
  6. Centers for Disease Control and Prevention. Developmental screening tools. Developmental screening and assessment instruments with an emphasis on social and emotional development for young children ages birth through five. May 2008. Available at: http://www.nectac.org/~pdfs/pubs/screening.pdf. Accessed on December 19, 2016.
  7. Centers for Medicare & Medicaid Services. National Coverage Determination for Institutional and Home Care Patient Education Programs. NCD#170.1. Effective date not posted. Available at: http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on December 19, 2016.
  8. Miller EL, Murray L, Richards L, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke. 2010; 41(10):2402-2448.
  9. NIH Consensus Statement. Rehabilitation of persons with traumatic brain injury. 1998; 16(1):1-41. Available at: http://www.nichd.nih.gov/publications/pubs/TBI_1999/Pages/NIH_Consensus_Statement.aspx. Accessed on December 19, 2016.
Index

Occupational Therapy
OT (Occupational Therapy)

History

Status

Date

Action

  12/27/2017

The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2018 CPT and HCPCS changes; added 97127, 97763, G0515 and modifiers 96, 97; revised descriptors for 97760, 97761; removed 97532, 97762 and modifier SZ deleted 12/31/2017.

Revised 02/02/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Clarified MN and NMN habilitative therapy criteria. Reformatted Clinical Indications section. Updated Definitions and References sections.
  01/01/2017 Updated Coding section with 01/01/2017 CPT changes; removed codes 97003, 97004 deleted 12/31/2016.
Revised 05/05/2016 MPTAC review. Defined abbreviation in rehabilitative NMN section. Updated references. Removed ICD-9 codes from Coding section.
Reviewed 05/07/2015 MPTAC review. Updated Coding, Description and References.
Revised 11/13/2014 MPTAC review. Clarified medically necessary criteria for habilitative services. Clarified note for rehabilitative and habilitative therapy. Updated References.
Revised 05/15/2014 MPTAC review. Clarified medically necessary criteria for rehabilitative OT services. Revised medically necessary criteria to address habilitative OT services. Clarified not medically necessary criteria for rehabilitative OT services; duplicate rehabilitative therapy and maintenance therapy. Revised not medically necessary criteria to address habilitative OT services. Updated Description, Definitions, References and Websites. Updated coding section with HCPCS modifier '-SZ' effective 07/01/2014.
Reviewed 02/13/2014 MPTAC review. Websites and Coding updated.
Reviewed 02/14/2013 MPTAC review.
Reviewed 08/09/2012 MPTAC review. References and Websites updated.
  01/01/2012 Updated Coding section to include 01/01/2012 CPT changes; removed revenue codes 0430-0439.
Reviewed 08/18/2011 MPTAC review. References and Websites updated.
  01/01/2011 Updated Coding section with 01/01/2011 CPT and HCPCS changes.
Reviewed 08/19/2010 MPTAC review. Websites and references updated.
  01/01/2010 Updated Coding section with 01/01/2010 HCPCS changes.
Reviewed 08/27/2009 MPTAC review. Removed Place of Service/Duration. References and coding updated.
Reviewed 08/28/2008 MPTAC review. References updated.
Reviewed 08/23/2007 MPTAC review. Coding section updated.
Revised 09/14/2006 MPTAC review. Minor revision to Not Medically Necessary statement. References updated. Coding updated: removed CPT 97504, 97520, 97703 deleted 12/31/05 (see historical document).
Revised 12/01/2005 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations

Last Review Date

Document Number

Title

 

Anthem Midwest

08/06/2004

RA-008 (Midwest Medical Review & UM criteria) Physical Therapy / Occupational Therapy For NASCO, Prestandardized Medicare Supplement Plans, Group Blue Retiree Products, and FEP
WellPoint Health Networks, Inc.

04/28/2005

10.01.07 Occupational Therapy