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 28, 2013

Revision Date(s) 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 services may be considered medically necessary when performed to treat the functional needs of a patient who suffers from physical impairment, functional limitation or disability due to disease, trauma, congenital anomalies, or prior therapeutic intervention.

Maintenance programs are considered not medically necessary.

Home-based Occupational Therapy

Home-based occupational therapy may be considered medically necessary when the member is homebound. See Policy Guidelines for definition of homebound.

Related Policies

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7.01.551

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

8.03.500

Sensory Integration Therapy

8.03.502

Physical Medicine and Rehabilitation – Physical Therapy and Medical Massage Therapy

8.03.504

Cognitive Rehabilitation

8.03.505

Speech Therapy

10.01.500

Skilled Nursing Care in the Home

Policy Guidelines

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Occupational therapy (OT) services must meet ALL of the following criteria:

  • The patient has a documented physical impairment, functional limitation or disability due to disease, trauma, congenital anomalies, or prior therapeutic intervention AND
  • The OT plan includes realistic individual goals that are clearly identified and are likely to be met within a predictable timeframe AND
  • The OT service is delivered by a qualified provider of OT services. A qualified provider is one who is licensed and performs within the scope of his/her licensure or practice; 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.

Definitions

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 is not determined by the lack of available transportation or inability to drive. 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 members with a poor resistance to disease are premature infants, members undergoing chemotherapy, and those 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 (ADLs) (i.e.as transferring, walking or eating etc.).

Maintenance 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 would not be covered.

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

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

Activities of Daily Living (ADL)

ADL training including, but not limited to, bathing, feeding, preparing meals, toileting, walking, making a bed, and transferring from bed to chair, wheelchair or walker, are covered when the skills of professional provider are required, and the treatment plan is designed to address the specific 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.

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.

Non-Skilled Services

Certain types of treatment do not generally require the skills of a qualified provider of OT and are, therefore, not medically necessary. Services may include:

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

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.

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.

Sessions

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:

  • 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.

Plan of Care and Documentation

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

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

Duplicate Therapy

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.

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 for the period April 2012 March 2013. 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. (1) 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. (2)

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. (3)

References

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  1. American Occupational Therapy Association. Standards of practice for occupational therapy. 2010. Available at URL address: http://www.aota.org/about/core/36194.aspx. Last accessed April 4, 2013.
  2. Moyers PA. The guide to occupational therapy practice. American Occupational Therapy Association. Am J Occup Ther. 1999; 53(3): 247-322. Available at URL address: http://ajot.aotapress.net/content/53/3/247.full.pdf+html. Last accessed April 4, 2013.
  3. 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. Available at URL address: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2048861/. Last accessed April 4, 2013.
  4. 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. Available at URL address: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Last accessed April 4, 2013.
  5. BlueCross BlueShield Association. Occupational Therapy. 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

ICD-9 Procedure

93.83

Occupational therapy

ICD-9 Diagnosis

 

Code applicable conditions

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

ICD-10 CM Procedure
(effective 10/01/14)

F08Z0EZ

Bathing/Showering Techniques Treatment using Orthosis

 

F08Z0FZ

Bathing/Showering Techniques Treatment using Assistive, Adaptive, Supportive or Protective Equipment

 

F08Z0UZ

Bathing/Showering Techniques Treatment using Prosthesis

 

F08Z0YZ

Bathing/Showering Techniques Treatment using Other Equipment

 

F08Z0ZZ

Bathing/Showering Techniques Treatment

 

F08Z1EZ

Dressing Techniques Treatment using Orthosis

 

F08Z1FZ

Dressing Techniques Treatment using Assistive, Adaptive, Supportive or Protective Equipment

 

F08Z1UZ

Dressing Techniques Treatment using Prosthesis

 

F08Z1YZ

Dressing Techniques Treatment using Other Equipment

 

F08Z1ZZ

Dressing Techniques Treatment

 

F08Z2EZ

Grooming/Personal Hygiene Treatment using Orthosis

 

F08Z2FZ

Grooming/Personal Hygiene Treatment using Assistive, Adaptive, Supportive or Protective Equipment

 

F08Z2UZ

Grooming/Personal Hygiene Treatment using Prosthesis

 

F08Z2YZ

Grooming/Personal Hygiene Treatment using Other Equipment

 

F08Z2ZZ

Grooming/Personal Hygiene Treatment

 

F08Z3CZ

Feeding/Eating Treatment using Mechanical Equipment

 

F08Z3DZ

Feeding/Eating Treatment using Electrotherapeutic Equipment

 

F08Z3EZ

Feeding/Eating Treatment using Orthosis

 

F08Z3FZ

Feeding/Eating Treatment using Assistive, Adaptive, Supportive or Protective Equipment

 

F08Z3UZ

Feeding/Eating Treatment using Prosthesis

 

F08Z3YZ

Feeding/Eating Treatment using Other Equipment

 

F08Z3ZZ

Feeding/Eating Treatment

 

F08Z4DZ

Home Management Treatment using Electrotherapeutic Equipment

 

F08Z4EZ

Home Management Treatment using Orthosis

 

F08Z4FZ

Home Management Treatment using Assistive, Adaptive, Supportive or Protective Equipment

 

F08Z4UZ

Home Management Treatment using Prosthesis

 

F08Z4YZ

Home Management Treatment using Other Equipment

 

F08Z4ZZ

Home Management Treatment

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.


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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