| Utilization Management Section - Occupational
Therapy (OT)
| Topic: Occupational Therapy (OT) |
Date of Origin: 06/1994 |
| Section: Utilization Management |
Policy No: 4 |
| Approved Date: 01/13/2009 |
Effective Date: 08/01/2009 |
| Next Review Date: 08/2010 |
|
IMPORTANT REMINDER
This Medical Policy has been developed through consideration of medical necessity,
generally accepted standards of medical practice, and review of medical literature
and government approval status.
Benefit determinations should be based in all cases on
the applicable contract language. To the extent there are any conflicts
between these guidelines and the contract language, the contract language will
control.
The purpose of medical policy is to provide a guide to coverage. Medical Policy
is not intended to dictate to providers how to practice medicine. Providers
are expected to exercise their medical judgment in providing the most appropriate
care.
Description
Occupational therapy is a form of rehabilitation involving
the treatment of neuromusculoskeletal and psychological
dysfunction. The use of specific tasks or
goal-directed activities is designed to improve
the functional performance of an individual.
Occupational therapy involves cognitive, perceptual,
safety, and judgment evaluations and training. These
services emphasize useful and purposeful activities
to improve neuromusculoskeletal functions and 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 adaptive
equipment. Occupational therapists may specialize in
hand rehabilitation, seating and pediatrics.
Policy/Criteria
| I. |
Occupational therapy may be medically
necessary when all of the following criteria are
met: |
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A. |
Services
are for the treatment of a covered injury, illness
or disease and are appropriate treatment for the
condition |
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B. |
Treatments
are expected to result in significant, functional
improvement in a reasonable, and generally predictable
period of time, or are necessary for the establishment
of a safe and effective maintenance program. Treatments
should be directed towards restoration or compensation
for impaired function. The improvement potential
must be significant in relation to the extent and
duration of therapy required |
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C. |
Therapy
is prescribed by an eligible provider as defined
by the contract |
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D. |
Therapy
is rendered by an eligible provider as defined
by the member contract |
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E. |
The services
must be currently accepted standards of medical
practice and specific and effective treatment for
the patient’s existing condition |
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F. |
The complexity
of the therapy and the patient's condition must
require the judgment and knowledge of a physician
or a licensed occupational therapist |
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G. |
Services
do not duplicate those provided concurrently by
any other therapy, particularly physical therapy |
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H. |
Services
are not for the treatment of psychological
conditions |
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| II. |
If the
above criteria are met, the following guidelines
apply: |
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A. |
The treatments
listed below require the skills and expertise of
a licensed licensed eligible provider. In conjunction
with delivering these services, the provider is
expected to provide teaching and training to the
patient/family members/caregivers. Maintenance
programs must be taught before the end of the active
rehabilitation program. |
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1) |
Joint protection and/or
splint fabrication |
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2) |
Body mechanics, including
home safety |
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3) |
Strengthening exercises
to restore impaired function |
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4) |
Integration of eating
and swallowing |
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5) |
Facilitation techniques
to restore or remediate motor dysfunction |
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B. |
Activities
of daily living |
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1) |
Work simplification
and/or energy conservation |
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2) |
Exercise for upper
extremity muscle groups |
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3) |
Functional activities:
self-care training in dressing, feeding, bathing,
toileting, hygiene, grooming, and transfers |
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4) |
Assessment of home
safety and equipment needs |
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C. |
Perceptual
motor |
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1) |
Perceptual exercise/training |
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2) |
Body cognitive training |
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3) |
Figure-ground discrimination |
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4) |
Eye-hand coordination |
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5) |
Visual tracking |
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6) |
Spatial relationship |
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7) |
Field cut compensation |
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8) |
Left-right discrimination |
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| III. |
The following
services are not considered medically necessary
when provided solely for the purpose of: |
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|
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A. |
Training
in non-essential self-help or recreational tasks
(e.g., homemaking, gardening, vocational and educational
activities, cooking, driving, assistance with finances,
scheduling) |
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B. |
Maintenance
therapy |
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|
Maintenance
therapy is defined as ongoing therapy after the
patient has reached maximum rehabilitation potential,
or functional level has shown no significant improvement
for two weeks, and initial instruction in a maintenance
program is completed. This is particularly applicable
to patients with chronic, stable conditions where
skilled supervision/interventions is no longer
required and further clinical improvement cannot
reasonably be expected from continuous ongoing
care. This includes but is not limited to: |
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1) |
Therapy that is supportive
rather than corrective in nature |
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2) |
Therapy that is intended
to maintain a gradual process of healing or to
prevent deterioration or relapse |
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3) |
Ongoing treatment solely
to improve endurance, strength or distance |
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4) |
Passive exercises to
maintain range of motion that can be carried out
by nonskilled persons |
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5) |
A general exercise
program to promote overall fitness |
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6) |
Therapy that is intended
to provide diversion or general motivation |
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7) |
Treatment that seeks
to prevent disease, promote health, and prolong
and enhance quality of life |
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C. |
Instruction
of other agency or professional personnel in the
patient’s occupational therapy program |
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D. |
Collaboration
with other agency or professional personnel or
with other community resources |
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E. |
Emotional
support, adjustment to extended hospitalization
and/or disability, and behavioral readjustment |
References
- BlueCross BlueShield Association Medical Policy
Reference Manual, Policy No. 8.03.03
Cross References
Physical
Therapy, Regence Medical Policy Manual, Utilization
Management, Policy No. 6
Speech
Therapy, Regence Medical Policy Manual, Utilization
Management, Policy No. 9
Cognitive
Rehabilitation, Regence Medical Policy Manual,
Allied Health, Policy No. 20
| Codes |
Number |
Description |
| CPT |
97003 |
Occupational therapy evaluation |
| |
97004 |
Occupational therapy re-evaluation |
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97110-97530 |
Therapeutic procedures, code range |
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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 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 |
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G0152 |
Services of occupational therapist
in home health setting, each 15 minutes |
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S9129 |
Occupational therapy; in the home per diem |
Utilization Management Table of Contents 
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