Occupational therapy (OT) is a form of rehabilitation involving the use of activities that have a purpose and are goal-directed to restore or improve functional performance and increase the ability to perform life tasks.

Occupational therapy addresses the physical, cognitive, psychosocial, sensory, and other aspects of performance in a variety of contexts to support engagement in everyday life activities that affect health, well being, and quality of life for people of all ages. These services are performed in the outpatient, office, or home setting which emphasize techniques that assist the client in acquiring the knowledge, skills and attitudes necessary for the performance of required life tasks including activities of daily living (ADLs), instrumental activities of daily living (IADLs), and daily life functional skills. ADLs include bathing, dressing, eating, feeding, functional mobility, personal device care, personal hygiene, grooming, and toilet hygiene. IADLs include care of others, providing the care and supervision to support the developmental needs of a child, communication device use, community mobility, financial management, meal preparation, and cleanup. Other occupational therapy services include the design, fabrication, and use of orthoses, and guidance in the selection and use of adapted equipment. Occupational therapy does not include diversional, recreational, and vocational therapies (such as hobbies, arts and crafts).

Note: Many benefit plans 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 MED.00107 Medical and Other Non-Behavioral Health Related Treatments for Pervasive Developmental Disorders

Medically Necessary:

Occupational therapy (OT) services are considered medically necessary when ALL following criteria are met:

1. The therapy is aimed at preventing disability or 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
   • An individual's function could not reasonably be expected to improve as the individual gradually resumes normal activities; and
   • 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
   • 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. A qualified provider is one who is licensed where required and performs within the scope of licensure; 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.

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:

• Prior functional level, if acquired condition;
• Specific standardized and non-standardized tests, assessments, and tools;
• Analytic interpretation and synthesis of all data, including a summary of the baseline findings in written report(s);
• Objective, measurable, and functional descriptions of an individual's deficits using comparable and consistent methods;
• Summary of clinical reasoning and consideration of contextual factors with recommendations;
• Plan of care with specific treatment techniques or activities to be used in treatment sessions that should be updated as the individual's condition changes;
• Frequency and duration of treatment plan;
• Functional, measurable, and time-framed long-term and short-term goals based on appropriate and relevant evaluation data;
• Rehabilitation prognosis;
• Discharge plan that is initiated at the start of OT treatment.

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:

• Evaluation;
• Therapeutic use of everyday life activities;
• Treating underlying impairments in preparation for the individual's engagement in purposeful activity (occupation);
• Compensation, modification, or adaptation of activity or environment to enhance performance;
• Management of feeding, eating, and swallowing to enable eating and feeding performance;
• Basic activities of daily living, self-care, self-management, and home management;
• Higher level independent living skills instruction and community/work integration;
• Modification of environments (home, work, school, or community) and adaptation of processes, including the application of ergonomic principles;
• Assessment, design, fabrication, application, fitting, and training in assistive technology, adaptive devices, and orthotic devices;
• Training in the use of prosthetic devices;
• Functional community mobility;
• Functionally oriented upper extremity exercise programs;
• Cognitive, perceptual, safety, and judgment evaluations and training;
• Training of the individual, caregivers, and family/parents in home exercise and activity programs;
• Skilled reassessment of the individual's problems, plan, and goals as part of the treatment session;
• Coordination, communication, and documentation;
• Reevaluations, if there is a significant change in the individual's condition.

Documentation of treatment sessions must include:

• Date of treatment;
• Specific treatment(s) provided that match the procedure codes billed;
• Total treatment time;
• The individual's response to treatment;
• Skilled ongoing reassessment of the individual's progress toward the goals;
• Any progress toward the goals in objective, measurable terms using consistent and comparable methods;
• Any problems or changes to the plan of care;
• Name and credentials of the treating clinician. 

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:

• Start of care date;
• Time period covered by the report;
• Medical and therapy treatment diagnoses;
• Statement of the individual's functional level at the beginning of the progress report period;
• Statement of the individual's current status as compared to evaluation baseline data and the prior progress report, including objective measures of the individual's function that relate to the treatment goals;
• Changes in prognosis and why;
• Changes in plan of care and why;
• Changes in goals and why;
• Consultations with other professionals or coordination of services, if applicable;
• Signature and title of qualified professional responsible for the therapy services.

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:

• Data collection with objective measurements based on appropriate and relevant assessment tests and tools using comparable and consistent methods;
• Making a judgment as to whether skilled care is still warranted; 
• Organizing the composite of current problem areas and deciding a priority/focus of treatment; 
• Identifying the appropriate intervention(s) for new or ongoing goal achievement; 
• Modification of intervention(s);
• Revision in plan of care if needed;  
• Correlation to meaningful change in function; and
• Deciphering effectiveness of intervention(s).

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.

Not Medically Necessary:

Occupational therapy (OT) services are considered not medically necessary if any of the following is determined:

1. The therapy is not aimed at preventing disability or 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 educationally-based (i.e., via school systems) or involves 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:
   • If function could reasonably be expected to improve as the individual gradually resumes normal activities, then therapy is considered not medically necessary.
   • 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.
   • 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 Therapy
Duplicate 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.

Maintenance Program
Maintenance programs are considered not medically necessary. A maintenance therapy program consists of treatments or activities that 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 further functional progress is apparent or expected to occur. In certain circumstances, the specialized knowledge and judgment of a qualified therapist maybe required to establish a maintenance program, however, the repetitive OT services to maintain a level would be considered not medically necessary.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  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. 

Peer Reviewed Publications         

1. Law M, Stewart D, Letts, L, et al Effectiveness of activity programmes for older persons with dementia. A critical review of the literature by the Occupational Therapy Evidence-based Practice Research Group. 1998. Available at: http://www.fhs.mcmaster.ca/rehab/ebp/pdf/activity.pdf. Accessed on January 16, 2013.
2.  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.
3.  Moyers, P.A. The guide to occupational therapy practice. American Occupational Therapy Association. Am J Occup Ther. 1999; 53(3):247-322.
4.  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.
5.  Steultjens EM, Dekker J, Bouter et al. Evidence of the efficacy of occupational therapy in different conditions: an overview of systematic reviews. Clin Rehabil. 2005; 19(3):247-254.

Government Agency, Medical Society, and Other Authoritative Publications

1. American Occupational Therapy Association, Inc. (AOTA). Occupational therapy professionals factsheet: Work rehabilitation. Last updated 03/28/2012. Available at: http://www.aota.org/Consumers/Professionals/WhatIsOT/WI/Facts/Work-Rehab.aspx. Accessed on January 16, 2013.
2. American Occupational Therapy Association. Guidelines for supervision, roles, and responsibilities during the delivery of occupational therapy services. American Journal of Occupational 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. June 9, 2008. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed on January 16, 2013.
4. Centers for Medicare & Medicaid Services. Manuals. Available at: http://www.cms.hhs.gov/Manuals/PBM/list.asp. Accessed on January 16, 2013
   • Home Health Agency Manual. Pub. 11. Chapter 2, Section 205.2. Coverage of Services Which Establish Home Health Eligibility. Skilled Therapy Services. Last updated September 8, 2005.
   • 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 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 January 16, 2013.
6. NIH Consensus Statement. Rehabilitation of persons with traumatic brain injury. 1998 Oct 26-28; 16(1): 1-41. Available at: http://www.nichd.nih.gov/publications/pubs/TBI_1999/Pages/NIH_Consensus_Statement.aspx. Accessed on January 16, 2013.

Occupational Therapy
OT (Occupational Therapy)