MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Occupational Therapy

Number 8.03.503

Effective Date May 5,2014

Revision Date(s) 04/14/14; 05/13/13; 05/08/12; 05/10/11; 05/11/10; 06/09/09; 07/08/08; 10/09/07; 03/08/05; 12/10/02; 05/05/97

Replaces 8.03.03

Policy

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Occupational therapy (OT) services may be considered medically necessary when criteria are met.

Occupational therapy (OT) may be considered medically necessary when ALL of the following criteria are met:

  • The patient has a documented physical functional impairment or disability due to disease, trauma, congenital anomalies, or prior therapeutic intervention AND
  • The patient has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time based on specific diagnosis-related treatment/therapy goals AND
  • The OT service is delivered by a qualified provider of OT services AND
  • Due to the physical condition of the patient, the complexity and sophistication of the therapy and the therapeutic modalities used; the judgment, knowledge, and skills of a qualified OT provider are required.

OT may be considered not medically necessary when criteria are not met.

Home-based Skilled Occupational Therapy

Home-based skilled occupational therapy may be considered medically necessary when the member is homebound and other medically necessary criteria in this policy are met.

Duplicate Therapy

Duplicate therapy may be considered not medically necessary. (e.g.. when Occupational and physical therapy provide the same treatment for the same diagnosis).

Maintenance Occupational Therapy

Maintenance OT programs are considered not medically necessary.

Non-skilled Occupational Therapy

Certain types of treatment that do not generally require the skills of a qualified OT provider are considered not medically necessary. (See Policy Guidelines).

Related Policies

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7.01.551

Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, Laminotomy, Laminectomy

8.03.500

Sensory and Auditory Integration Therapy

8.03.502

Physical Medicine and Rehabilitation – Physical Therapy and Medical Massage Therapy

8.03.505

Speech Therapy

10.01.500

Skilled Home Health Care Services

Policy Guidelines

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Additional skilled services of an occupational therapist may include, but are not limited to, training the patient, family members and/or unskilled persons, making a skilled assessment of the living setting for threats to patient safety with recommendations for adaptation and infrequent but not routine reevaluations of the patient’s progress with revisions to the treatment plan.

Plan of Care

When the skills of the OT are required to assist the patient and/or train a family member caregiver, the treatment plan must address the specific physical functional impairment(s) and the needs of the patient. Specific outcomes must be identified. Services provided concurrently by occupational therapists and physical therapists may be covered if there are separate and distinct functional goals.

Duplicate Therapy

When patients receive occupational and physical or speech therapy, the therapists should provide different treatments and not duplicate the same treatment. They must also have separate plans of care and goals.

Definition of Terms

Activities of Daily Living (ADL)

ADLs are self-care activities done daily within a member’s place of residence and includes:

  • Dressing/bathing,
  • Eating,
  • Ambulating (walking),
  • Transferring,
  • Toileting,
  • Hygiene (grooming).

Homebound

A homebound patient has a condition that impairs their ability to leave home independently and as a result, leaving home requires a taxing effort. (The patient may leave home, but the time away should be short, infrequent, and mainly for receiving medical treatment). Homebound status may be applied to members with compromised immune status or such poor health that reverse isolation precautions are recommended by their providers to avoid exposure to infection(s).

Examples of a poor resistance to disease may include but are not limited to:

  • Premature infants, or
  • Patients undergoing chemotherapy, or
  • Patients with a chronic disease that has lowered their immune status.

Homebound status also applies to those members that require assistance when performing activities of daily living.

Note: Homebound status is not determined by the lack of available transportation or inability to drive.

Instrumental Activities of Daily Living (IADLs)

IADLs are activities related to independent living (1) but not always done on a daily basis and include:

  • Communication (using the telephone, computer or other communication devices)
  • Housework/home maintenance
  • Managing personal finances
  • Managing medications
  • Preparing meals
  • Shopping
  • Transportation (driving or using public transit)

Maintenance Therapy Program

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. This may apply to patients with chronic and stable conditions where skilled supervision is no longer required and clinical improvement is not expected. The specialized knowledge and judgment of a qualified therapist may be required to establish a maintenance program; however, the repetitive occupational therapy services necessary to maintain a level of function are not covered.

Types of maintenance therapy may include, but are not limited to the following:

  • A general home exercise program
  • Ongoing occupational therapy to maintain a static level of function when the member’s chronic medical condition has reached maximum functional improvement
  • Passive stretching exercises that maintain range of motion and are performed by non-skilled personnel
  • Therapy services that enhance performance beyond basic functional ability

Non-Skilled Services

Non-skilled services are services that could be done safely by the patient or a non-medical person without the supervision of a skilled OT.

Non-Skilled Services may include but are not limited to:

  • Activities which the patient performs without direct supervision of a qualified provider for general conditioning or preserving function;
  • Passive range of motion (PROM) treatment that is not related to restoration of a specific loss of function;
  • Treatment modalities that the patient self-applies without direct supervision of qualified provider such as traction;

Physical Functional Impairment

Physical functional impairment means a limitation from normal (or baseline level) of physical functioning that may include, but is not limited to, problems with ambulation, mobilization, communication, respiration, eating, swallowing, vision, facial expression, skin integrity, distortion of nearby body parts or obstruction of an orifice. The physical functional impairment can be due to structure, congenital deformity, pain, or other causes. Physical functional impairment excludes social, emotional and psychological impairments or potential impairments.

Description

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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 describes rehabilitation that is directed at specific environments (i.e. home or work) and the patient’s ability to function in that setting.

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.

Scope

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Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

Benefit Application

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In some plans, the available occupational therapy benefit is defined by a specific number of treatment sessions covered per year regardless of the condition or number of courses of therapy ordered by the primary health care provider.

Session of Treatment

An occupational therapy session is defined as up to one hour of occupational therapy (treatment and/or evaluation) on any given day. These sessions may include services such as:

  • activities of daily living (ADLs) and self-care training;
  • level independent living skills instruction;
  • oriented upper extremity exercise programs;
  • perceptual, safety, and judgment evaluations and training;
  • extremity orthotic and prosthetic programs; and
  • of the patient and family in home exercise programs.

Plan of Care and Documentation

A legible written plan of care must be made and include:

  • key for any codes that are used; and
  • statements of long and short-term goals; and
  • objectives; and
  • reasonable estimate of when the goals will be reached; and
  • specific modalities and exercises to be used in treatment; and
  • frequency and duration of treatment; and
  • at the end of the plan and a new plan of care created before further treatment is provided; and
  • at the end of the treatment plan by the referring provider with treatment recommendations, if further care is needed.

Daily record of the treatment provided is required. Brief notations, check boxes, and codes/symbols for the procedures (e.g., neuromuscular re-education (NMR), myofascial release (MFR), hot packs (HP) can be used in daily notes only when the notations refer to the current plan of care.

Use of Symbols and Codes

A key for any symbols or codes that are used by the provider and/or staff providing occupational therapy must be included in the patient’s health care records.

Rationale

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This policy was initially developed 1997. The policy has been reviewed on a regular basis using MEDLINE literature searches. The most recent literature search was conducted through February, 2014. Following is a summary of the key literature.

Occupational therapy is a medically prescribed treatment focused on improving or restoring functions that have been impaired by illness, injury, prior therapeutic intervention (e.g. hand surgery, joint replacement) or where function has been permanently lost or reduced by disease, trauma, or congenital anomalies. The outcome of therapy is to improve the individual’s ability to perform those tasks or activities of daily living (ADLs) required for independent functioning.

The American Occupational Therapy Association (AOTA) describes occupational therapy as services provided for the purpose of promoting health and wellness and to those who have or are at risk for developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction. Occupational therapy addresses physical, cognitive, psychosocial, sensory, communication, and other areas of performance in various contexts and environments in everyday life activities that affect health, well-being, and quality of life. (2) Occupational therapy practitioners use their expertise to maximize the fit between what it is the individual wants and needs to do and his/her capacity to do it. The patient’s participation in therapy when coupled with the skilled intervention of the occupational therapy practitioner can often effectively resolve or compensate for health-related functional performance limitations. (3)

In 2007 Legg et al. published a systematic review and meta-analysis of 9 randomized control trials of occupational therapy (OT) delivered to 1258 patients after stroke. The objective was to determine if OT services that focused on personal ADLs improved patients’ recovery after stroke. The data sources used were The Cochrane stroke group trials register, the Cochrane central register of controlled trials, Medline, Embase, CINAHL, PsycLIT, AMED, Wilson Social Sciences Abstracts, Science Citation Index, Social Science Citation, Arts and Humanities Citation Index, Dissertations Abstracts register, Occupational Therapy Research Index, scanning reference lists, personal communication with authors, and hand searching. Two reviewers independently reviewed each trial for methodological quality. Disagreement was resolved by consensus. The results of the review were that OT delivered to patients after stroke and targeted towards personal activities of daily living increased performance scores (standardised mean difference 0.18, 95% confidence interval 0.04 to 0.32, P=0.01) and reduced the risk of poor outcome (death, deterioration or dependency in personal activities of daily living) (odds ratio 0.67, 95% confidence interval 0.51 to 0.87, P=0.003). For every 100 people who received occupational therapy focused on personal activities of daily living, 11 (95% confidence interval 7 to 30) would be spared a poor outcome. The authors concluded stroke patients who receive occupational therapy focused on personal activities of daily living, as opposed to no routine occupational therapy, are more likely to be independent in those activities. (4)

References

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  1. HHS. Measuring the activities of daily living: Comparison across national surveys. 1990. Source URL: http://aspe.hhs.gov/daltcp/reports/meacmpes.htm. Last accessed March 2014.
  2. American Occupational Therapy Association (AOTA). Standards of practice for occupational therapy. 2010. Source URL: http://www.aota.org/about/core/36194.aspx. Last accessed March, 2014.
  3. Moyers PA. The guide to occupational therapy practice. American Occupational Therapy Association. Am J Occup Ther. 1999; 53(3): 247-322. Source URL: http://ajot.aotapress.net/content/53/3/247.full.pdf+html. Last accessed March, 2014.
  4. Legg L, et al. Occupational therapy for patients with problems in personal activities of daily living after stroke: systematic review of randomized trials. BMJ. 2007 November 3; 335(7626): 922. Source URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2048861/. Last accessed March, 2014.
  5. 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, January 2013 and Section 230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology, January 2007. Source URL: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Last accessed March, 2014.
  6. BlueCross BlueShield Association (BCBSA). Occupational Therapy-Archived. Medical Policy Reference Manual: Policy No. 8.03.03, 2011.

Coding

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Codes

Number

Description

CPT

97003

Occupational therapy evaluation

 

97004

Occupational therapy re-evaluation

 

97140

Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

 

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

HCPCS

G0129

Occupational therapy requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per day

 

G0152

Service of occupational therapist in home health 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 therapy maintenance program, each 15 minutes

 

S9129

Occupational therapy, in the home, per diem

Type of Service

Medical

 

Place of Service

Inpatient / Outpatient

Occupational Therapist’s Office

 

Appendix

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N/A

History

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Date

Reason

05/05/97

Add to Therapy Section - New Policy

12/10/02

Replace Policy - Policy reviewed without literature review; new review date only.

03/08/05

Replace Policy - Policy reviewed without literature review; new review date only.

06/23/06

Update Scope and Disclaimer - No other changes.

7/10/07

Cross Reference Update - No other changes.

10/09/07

New PR Policy - Policy replaces AR.8.03.03. Policy statement amended to list maintenance programs as not medically necessary. Rationale updated with documentation requirements for treatment.

05/13/08

Cross References Updated - No other changes.

07/08/08

Replace Policy - Policy updated with literature search; no change to the policy statement.

08/12/08

Cross References Updated - No other changes.

06/09/09

Replace Policy - Policy updated with literature search; no change to the policy statement.

05/11/10

Replace Policy - Policy updated with literature search; no change to the policy statement.

05/10/11

Replace Policy - Policy updated with literature search; no change to the policy statement. A definition of “homebound” has been added to the policy guidelines section.

05/22/12

Replace policy. HCPCS codes G0129 and G0160 added. CPT 97140 added. Policy updated with literature search, no new references added. Policy statements unchanged.

10/26/12

Update Related Policies. Title for 8.03.502 has been changed to say “Medical Massage Therapy”.

05/28/13

Replace policy. Added functional limitation or disability to policy statement. Policy guidelines revised for readability. Rationale section revised based on a literature review through March 2013. References 1-3 added. Policy statement changed as noted. Add ICD-10 codes.

01/21/14

Update Related Policies. Add 7.01.551.

05/05/14

Annual Review. Added clarification to policy statements to include statement that Maintenance Therapy Program, Non-skilled services and Duplicate therapy are considered not medically necessary. Moved criteria from Policy Guidelines to Policy section. Updated Definition of Terms. A literature review through February 2014 did not prompt changes to the rationale section. No new references added. Policy statements changed as noted. ICD-9 procedure code 93.83 removed along with ICD-10 procedure codes; mostly paid through rehab benefit.

05/20/14

Update Related Policies. Remove 8.03.504 as it was archived.

12/01/14

Update Related Policies. Change title to 8.03.500.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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