Clinical UM Guideline


Subject:   Occupational Therapy
Guideline #:   CG-REHAB-05Current Effective Date:   05/19/2014
Status:   RevisedLast Review Date:   05/15/2014

Description

Occupational therapy services are skilled services which may be delivered by an occupational therapist or other health care professional acting within the scope of a professional license. Occupational therapy (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
    • 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 (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. In general, OT services for autism spectrum disorder and for other causes of developmental delay are habilitative services rather than rehabilitative services. See below for criteria for habilitative services.

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 (i.e., 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.
    • If function could reasonably be expected to improve as the individual gradually resumes normal activities, then the 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 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, develop or improve skills needed to perform ADLs or IADLs 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; and 
  2. The therapy is for a condition that requires the unique knowledge, skills, and judgment of a 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 maintain or improve the level of functioning; and
  4. An individual would either not be expected to develop the function or would be expected to permanently lose the function without the habilitative service (not merely fluctuate); and
  5. The therapy documentation objectively verifies that, at a minimum, functional status is maintained; and
  6. The services are delivered by a qualified provider of physical therapy services (see definition); and
  7. 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. In general OT services for autism spectrum disorder and for developmental delay are habilitative services rather than rehabilitative services.

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, improving, 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 
92605Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour
92618Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes
92606Therapeutic service(s) for the use of non-speech-generating device, including programming and modification
92607-92608Evaluation for prescription for speech-generating augmentative and alternative communication device
92609Therapeutic services for the use of speech-generating device, including programming and modification
92610Evaluation of oral and pharyngeal swallowing function
92611Motion fluoroscopic evaluation of swallowing function by cine or video recording
94667Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation
94668Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent
97003Occupational therapy evaluation
97004Occupational therapy re-evaluation
97010-97028Application of a modality to one or more areas (supervised) [includes codes 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028]
97032-97036Application of a modality to one or more areas (constant attendance) [includes codes 97032, 97033, 97034, 97035, 97036]
97039Unlisted modality [when not specified as a procedure that is considered investigational and not medically necessary]
97110-97139Therapeutic procedure, one or more areas [includes codes 97110, 97112, 97113, 97116, 97124, 97139]
97140Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
97150Therapeutic procedure(s), group  (2 or more individuals)
97530Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes
97532Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes
97533Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes
97535Self 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
97537Community/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
97542Wheelchair management (eg, assessment, fitting, training), each 15 minutes
97545-97546Work hardening/conditioning
97597-97598Debridement (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
97602Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session
97750Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes
97755Assistive 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
97760Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes
97761Prosthetic training, upper and/or lower extremity(s), each 15 minutes
97762Checkout for orthotic/prosthetic use, established patient, each 15 minutes
97799Unlisted physical medicine/rehabilitation service or procedure [when not specified as a procedure that is considered investigational and not medically necessary]
  
HCPCS 
G0129Occupational 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)
G0152Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes
G0158Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes
G0160Services 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
G0281Electrical 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
G0283Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
G0329Electromagnetic 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
S8950Complex lymphedema therapy, each 15 minutes
S8990Physical or manipulative therapy performed for maintenance rather than restoration
S9129Occupational therapy, in the home, per diem
  
 Note: HCPCS modifier '-SZ' may be used with the above procedure codes to indicate 'habilitative services'
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
  
Definitions

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

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, P.A. 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 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 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.
  2. 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. January 7, 2014. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed on April 3, 2014.
  3. Centers for Medicare & Medicaid Services. Manuals. Available at: http://www.cms.hhs.gov/Manuals/PBM/list.asp. Accessed on January 07, 2014.
    • 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.
  4. 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 April 3, 2014.
  5. 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;41:2402-2448.
  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 April 3, 2014.
Index

Occupational Therapy
OT (Occupational Therapy)

History

Status

Date

Action

Revised05/15/2014Medical Policy & Technology Assessment Committee (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.
Reviewed02/13/2014MPTAC review. Websites and Coding updated.
Reviewed02/14/2013MPTAC review.
Reviewed08/09/2012MPTAC review. References and Websites updated.
 01/01/2012Updated Coding section to include 01/01/2012 CPT changes; removed revenue codes 0430-0439.
Reviewed08/18/2011MPTAC review. References and Websites updated.
 01/01/2011Updated Coding section with 01/01/2011 CPT and HCPCS changes.
Reviewed08/19/2010MPTAC review. Websites and references updated.
 01/01/2010Updated Coding section with 01/01/2010 HCPCS changes.
Reviewed08/27/2009MPTAC review. Removed Place of Service/Duration. References and coding updated.
Reviewed08/28/2008MPTAC review. References updated.
Reviewed08/23/2007MPTAC review. Coding section updated.
Revised09/14/2006MPTAC review. Minor revision to Not Medically Necessary statement. References updated. Coding updated: removed CPT 97504, 97520, 97703 deleted 12/31/05 (see historical document).
Revised12/01/2005MPTAC 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

10.01.07Occupational Therapy