ARCHIVED

Medical Policy

Policy Num:       08.001.030
Policy Name:     OCCUPATIONAL THERAPY
Policy ID:          [08.001.030][Ac L M+ P ][0.00.00]

Last Review:       January 29, 2020
Next Review:       N/A
Issue:                   January, 2020

Archived

Related Policies:

08.001.003 HOME BASED OCCUPATIONAL THERAPY

08.001.002 Physical Therapy Services

08.001.001 Physical Therapy in the home

OCCUPATIONAL THERAPY

Summary

Occupational therapy is defined as that therapy which promotes the restoration of the ability of a person physically impaired to perform the tasks of daily living or the skills of a particular occupation.  Occupational therapy also includes activities specifically designed and tailored to a specific condition. 

These services emphasize the use of activities to improve neuromuscular and musculoskeletal function and provide training in the activities of daily living.  Other aspects of occupational therapy include the design, manufacture and use of the orthosis as well as instructions, assistance and selection of necessary equipment. 

For activities of daily living we mean those activities and skills necessary on a typical day such as: eating, bathing, dressing, physiological necessities, ambulating and mobility.

Objective

The objective of this evidence review is to determine whether occupational therapy improves the net health outcome in patients who are physically disabled due to disease, trauma, congenital anomalies or by condition due to a therapeutic intervention.

Policy Statements

Occupational therapy services are considered for payment when they are performed to address the need of a patient who is physically disabled due to disease, trauma, congenital anomalies or by condition due to a therapeutic intervention; these services must meet all the following criteria:

·         Those services that require the constant attention of a licensed occupational therapist (PT), a doctor of Medicine (MD), doctor of osteopathy (DO) or a chiropractor (DC).  This professional will arrive to a diagnosis and will identify those goals that can be reasonably met, will quantify the improvement within a reasonable time predictable. 

·         Provide an effective reasonable treatment and specific for the diagnosis of the patient and his physical condition. 

·         These services must be provided by a qualified provider and licensed by the relevant entities. 

·         These services will be provided as long as measurable progress is demonstrated with possibility of rehabilitation or any other necessary medical objective. 

Services that do not meet the above criteria will not be considered for payment.  Certain types of treatment that generally do not require the skills of a provider qualified in occupational therapy are not covered for payment.  These types of services include: 

·         Repetitive exercises to improve walking or running or provide resistance to unstable patients.

·         Ranges of passive movements (RPOM) not related to the restoration of a loss of specific function.

·         Infrared heat, paraffin baths and baths under any circumstances.

·         Preventive activities and maintenance.

·         Behavior disorder treatment.

·         Treatment of mental retardation.

·         Treatment of delayed development.

·         Treatment when there is no quantifiable progress when it pursues a restorable goal.

·         Services beyond those needed to restore the ability to carry out activities of daily living.

·         Services in which therapeutic benefits or possibility of improvement are not expected.

·         Services in which their duration is predetermined by a specific time rather than the condition of the patient, the results of treatment or medical progress of the patient.

·         Services that seek to improve the physical condition of the patient or the repetitive exercises or exercises using equipment to improve the strength and endurance.

·         Therapies or services that are considered to be part of custodial services.

·         Not supervised services.

·         Hospital care is not considered for payment if the admission to the hospital was for the purpose of receiving occupational therapy. 

Duplicate therapies are considered when the patient receives physical therapy and occupational therapy on the same day of service and the services are the same.  Two therapies must provide different treatments. 

Each therapy must have its own goals and treatment plan. 

·         If a patient visits a provider for physical therapy and another for occupational therapy they count as two visits.

·         If a patient visits a provider for physical therapy and occupational therapy they count as one visit.

Policy Guidelines

Necessary documentation: 

a.    Initial evaluation: a comprehensive evaluation is essential to determine if occupational therapy services are medically necessary or have enough data, establish a treatment plan and develop goals with that information.  An evaluation is required before implementing any treatment. 

A treatment plan must include: 

·         Previous functional level if the condition is acquired

·         Description of patient’s problem in an objective, functional and measurable manner.

·         Specific long and short-term goals

·         Measurable goals

·         A reasonable estimate of time in which goals and rehabilitation will be achieved.

·         Specific description of treatment techniques and activities to be used.

·         Frequency and duration of treatment.

·         A discharge plan      

b.      Progress report: preprinted reports are considered a component of the record or the patient’s file but are not sufficient by themselves. All notes about the duration of the treatment, modality, parameters, total time must be properly documented.  This information must be included in the medical record in a separate space in the preprinted form or in a SOAP note justifying the medical necessity and services to be billed.

Benefit Application

BlueCard/National Account Issues

As established in the member's contract/product.

Background

N/A

Regulatory Status

N/A

Rationale

Population Reference No. 1 Policy Statement

Individuals who are physically disabled due to disease, trauma, congenital anomalies or by condition due to a therapeutic intervention. Intervention of interest is occupational therapy. Comparators of interest are other therapies available. Relevant outcomes include improvement in the condition and overall quality of life.  The evidence is sufficient to determine that this therapy results in a meaningful improvement in the net health outcome.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1. Dorland's Illustrated Medical Dictionary, 27th Edition, 1988. 
2. Rheumatic Disease Clinic of North America (1990 November) 16(4):915-29.
3. Uniform Medical Policy Manual, Blue Cross and Blue Shield Association, September 1991, Allied Health, Physical Therapy, page 97010.0
4. Department of Health and Human Services, Office of Inspector General, Physical Therapy in the Physician's Office, March 1994.   
5. Journal of Burn Care Rehabilitation (1994 March-April) 15(2):143-6.
6. Advance for Physical Therapists, Vol. 2 (3), April 18, 1994, Convincing Insurers that Aquatic PT is more than a Splash in the Pool, page 24 through 26. 
7.  Tovin, B.J., Wolf, S.L., et al. Comparison of the Effects of Exercise in Water and on Land on the Rehabilitation of Patients With Intra-articular Anterior Cruciate Ligament Reconstructions. Physical Therapy (1994 August) 74(8).
8. Physical Therapy. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2002 April) Therapy 8.03.02.
9. Occupational Therapy. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2004 November) Therapy 8.03.03

Codes

Appplicable Modifiers

Some modifiers

Policy History