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General Guidelines
This policy discusses traditional Occupational Therapy assessments and
active therapies as performed in the facility outpatient (hospital, CORF,
etc.) and the Inpatient Rehabilitation Facility environment. These services
are not limited to Occupational Therapists but may also be performed by
Physical Therapists acting within their scope of practice. Assistants as
defined within Medicare regulations may also perform these services unless
otherwise specified in the regulations or in the text of this policy. Due
to the significant overlap between disciplines, the following related
policies should be referenced in order to obtain a complete picture of
coverage limitations:
Physical Therapy: The
Physical Therapy LCD discusses traditional Physical Therapy assessments and
active therapies regardless of the discipline performing the service.
PM&R Modalities: The PM&R Modalities LCD discusses
adjunctive modalities regardless of the discipline performing the service.
Wound Care: The Wound Care LCD discusses the routine care of chronic
wounds regardless of the discipline or provider performing the service.
Low Vision Rehabilitation: The Low Vision Rehabilitation LCD covers
Occupational Therapy interventions as they are used in programs to develop
compensatory techniques for the visually impaired.
Speech Therapy: The Speech Therapy LCD addresses Speech Therapy,
which occasionally overlaps with the services of other therapy disciplines.
Dysphagia Therapy: The Dysphagia Therapy LCD addresses therapeutic
interventions for dysphagia regardless of the discipline performing the
intervention.
Definition of Occupational Therapy Services
Occupational therapy services are a part of a constellation of
rehabilitative services designed to improve or restore physical functioning
following disease, injury, or loss of a body part or, where function has
been permanently lost or reduced by illness or injury, to improve the
individual's ability to perform those tasks required for independent
functioning. Current occupational therapy practice typically emphasizes
functionally based activities directed toward a goal of enhancing
performance through the adaptation of activity demands, the process or the
environment, or through instruction in compensatory techniques. Physical
therapists use the clinical history, systems review, physical examination,
and a variety of evaluative techniques to characterize individuals with
impairments, functional limitations and disabilities. Impairments,
functional limitations and disabilities thus identified are then addressed
in the design and implementation of therapeutic interventions tailored to
the specific needs of the individual patient. The Medicare Part B benefit
pays for Physical therapy services performed by or under the supervision of
Physical therapists that:
1)
practice within the scope of their state practice laws;
2) comply with Medicare coverage policy; and
3) are determined to be ‘reasonable and necessary’ for the individual
patient’s condition.
Reasonable and Necessary Skilled Services
Intervention with Occupational Therapy services is indicated when the
diagnosis established by the physician supports utilization of the
intervention; there is documentation of objective physical and functional
limitations; the plan of care incorporates those treatment elements that
are expected to result in improvement of these limitations in a reasonable
and generally predictable period of time (reasonable); and comparable
results would not be anticipated with this disease process in the absence
of the intervention (necessary). Intervention is also occasionally
warranted to establish a safe and effective maintenance program when such a
program is necessary to prevent deterioration in connection with a specific
disease.
In order to be considered for coverage, Occupational Therapy Services must
be medically reasonable and necessary to the treatment of the patient's
illness or injury. Medical necessity determinations will be based on the
following factors:
DIAGNOSIS SPECIFIC NECESSITY: The services must be considered under
accepted standards of medical practice to be a specific and effective treatment
for the patient's condition, i.e. specific, effective, and necessary for
the disability in the setting of the underlying disease process that caused
the disability.
·
The patient must have a physical impairment that creates a significant
functional limitation or dependence upon assistance or supervision from
another person for self-care or mobility services.
· Routine recovery periods for patients with certain illness are expected
without the services of a therapist. If comparable results would be
anticipated with a given disease process (e.g. routine post surgical
debilitation) in the absence of the intervention, the intervention of a
therapist is not medically necessary. In the unusual instance where skilled
Occupational Therapy services are required, the medical record must clearly
convey the necessity for skilled services of the therapist as opposed to
the presumptive need for restorative nursing care and unskilled custodial
assistance.
Examples of medically necessary skilled services:
·
The evaluation and reevaluation (as required) of a patient’s level of
function by administering diagnostic and prognostic tests;
· The selection and teaching of task-oriented therapeutic activities
designed to restore physical function;
· The planning, implementation, and supervision of individualized
therapeutic activity programs as part of an overall active treatment
program for a patient with a diagnosed psychiatric illness;
· The planning and implementation of therapeutic tasks and activities to
restore sensory-integrative function;
· The teaching of compensatory techniques to improve the level of
independence in the activities of daily living;
· The design, fabrication, and fitting of orthotic and self-help devices.
REASONABLE PROBABILITY OF IMPROVEMENT: The goal of services must
typically be to restore or improve functional ability. There must be a
reasonable expectation that significant improvement in the patient's
overall functional ability will occur in a reasonable and generally
predictable period of time. Complete restoration of function is often not
achievable but measurable and functionally significant improvement must be
considered a likely outcome.
In some instances the restoration potential of a patient is not the
deciding factor in determining whether skilled services are needed. Even if
improvement is not possible, a patient may need services to prevent further
deterioration or preserve current capabilities, or the services must be
necessary for the establishment of a safe and effective maintenance program
required in connection with a specific disease state. In most instances
ongoing maintenance does not require Occupational Therapy services (see
below). In the unusual instance that continued skilled Occupational Therapy
services are required to prevent further deterioration, the medical record
must clearly convey the necessity for skilled services of the therapist as
opposed to the presumptive need for unskilled maintenance services.
DEMONSTRATED PROGRESS: For continued coverage, the patient must
demonstrate significant and measurable functional progress over time.
Failure to progress over a several week period (“a plateau”) typically
indicates that there is no longer a reasonable expectation of improvement
in a “reasonable and generally predictable” period of time. In the unusual
instance that continued skilled Occupational Therapy services are required
due to a unique expectation of continued significant improvement, the
medical record must clearly convey the necessity for skilled services of a
therapist as opposed to the presumptive need for either unskilled
maintenance services or the termination of the episode of care.
APPROPRIATE TYPE, FREQUENCY AND DURATION: The type, frequency and
duration of services must be medically necessary for the patient's
disability and underlying medical condition under accepted medical and
occupational therapy practice standards.
TYPE
The type of service must be generally considered to be safe, effective,
necessary and appropriate for the disability and medical condition based
on:
·
General acceptance as standard of care by the medical and occupational
therapy disciplines in the United
States (typically well-established
services)
· Peer-reviewed and evidence based literature that supports the use of the
service (typically newer, potentially investigational, controversial or
unproven services).
Services of Occupational Therapists and Physical Therapists frequently are
required concurrently on the same patient. For a service to be medically
necessary when multiple disciplines are involved, it must not be
duplicative of a service provided by another discipline
FREQUENCY
·
Daily sessions (five times per week) are anticipated during the moderately
intensive program of a therapy based SNF stay
· Although daily sessions may be necessary during outpatient therapy,
particularly during the first week or two of a program or during a short
(2-4 week) intensive course of therapy, sessions occurring more than three
times weekly are not typically medically necessary for most outpatient
treatment regimens.
· In the outpatient or Skilled Nursing Facility environment it is usually
not medically necessary to have more than one treatment session per day.
More than 4 units of OT active therapy per day (including both individual
and group services) is not typically medically necessary; more than four
units (including no more than two untimed units) of individual active
therapy or five units (including no more than two untimed units) of
combined active and group therapy in a single day will be denied as
exceeding the normal needs for therapy outside of an IRF. However appeals
will not be bound by this determination in the event that rare and
exceptional situations are medically necessary and supported by additional
medical records. In atypical situations requiring daily interventions
(outpatient therapy where the intensive daily requirement exceeds two to
four weeks) or multiple daily sessions (SNF or outpatient), the medical
record must clearly justify the unusual medical need for services of this
intensity as opposed to a more typical level of intervention.
· Inpatient rehabilitation typically requires multiple or extended sessions
per day, either targeting several impairments (OT) or spread across several
disciplines (e.g. PT and OT).
DURATION
·
Depending on the severity of the patient's condition, the usual active
treatment session provided in the outpatient setting is from 45 to 60
minutes (excluding modalities) and is typically an hour or longer in the
IRF and inpatient Part A SNF environment.
· Atypical situations requiring shortened sessions should have the unusual
medical need clearly documented in the medical record.
RELATED TO TREATMENT PLAN:
By regulation, services must be directly related to a written plan of
treatment. Services (other than assessment) not relating to the written
treatment plan or performed prior to the development of the treatment plan
are not covered by regulation but are additionally considered not medically
necessary. They are considered not medically necessary since the
determination of patient needs and strategy for best meeting those needs
(the plan of care) has not yet been determined or does not address those
services.
Services performed under a treatment plan that has not been reviewed by a
physician within the timeframes specified by regulations (at least 90 days
after therapy began) are not covered by regulation but are additionally
considered not medically necessary. They are considered not medically
necessary since the patient’s medical needs change over time and in
response to therapy so the strategy for best meeting those changing medical
needs (the revised plan of care) has not been determined. If the referring
(patient’s treating) physician does not re-examine the patient as part of
the certification or recertification process, the medical necessity of
continued services will depend solely on clear and unambiguous
documentation in the therapy records to justify those services. (Note: This
LCD only discusses the demonstration of medical necessity. Administrative
requirements regarding certifications, physician examinations, etc are
covered in the Medicare regulations.)
SKILLED SERVICE:
Occupational therapy services are only covered when they are skilled
services. To be considered a skilled occupational therapy service, the
service must be so inherently complex that it can be safely and effectively
performed only by, or under the supervision of, an occupational therapist,
physician, or qualified personnel. Occupational therapy services that do
not require the professional skills of a qualified occupational therapist
to perform or supervise are not covered by regulation but are additionally
considered not medically necessary since the clinical (medical) skill of
the therapist is not medically indicated.
MAINTENANCE
Maintenance programs do not require the supervision of a therapist.
However, it may require the specialized knowledge and judgment of a
qualified therapist to design and establish a maintenance program based on
an initial evaluation and periodic reassessment of the patient's needs,
capacity, and tolerance, and to provide initial instruction for the patient
or family members to carry out the program. For example, a patient with
Parkinson's Disease who has not been under a rehabilitation regimen may
require the services of a qualified therapist to determine what type of
exercises will contribute the most to the maintenance of his present level
of functioning.
A brief period of practice may be required for the patient and/or patient’s
caregivers to learn the steps of the task, to verify the task’s
effectiveness in improving function, and to check for safe and consistent
performance. This is considered part of “establishing” the maintenance
program.
The skilled services of a therapist may be required for:
·
The design of a maintenance regimen to delay or minimize functional
deterioration in patients suffering from a chronic disease;
· Instructing the patient or family members in carrying out the maintenance
program; and,
· Infrequent reevaluations required to assess the patient's condition and
adjust the program.
The skilled services of a therapist are not required for:
·
Services related to activities for the general good and welfare of patients
(i.e., general exercises to promote overall fitness and flexibility);
· Repetitive exercises to maintain gait or maintain strength, endurance and
current level of functioning;
· Assisted walking such as that provided in support for feeble or unstable
patients;
· Range of motion and passive exercises that are not related to restoration
of a specific loss of function, but are useful in maintaining range of
motion in weakened or paralyzed extremities;
· Training programs related to occupational skills or skills that are
normally taught to unimpaired individuals and which would require no
significant modification for the patient;
· Maintenance therapies after the patient has achieved therapeutic goals;
and
· Therapies for patients who show no further meaningful progress.
NONSKILLED SERVICES
A condition that does not ordinarily require skilled services may require
them because of special medical complications. Under those circumstances, a
service that is usually non-skilled (such as those listed in
42CFR409.33(d)) may be considered skilled because it must be performed or
supervised by skilled rehabilitation personnel. In the unusual instance
where, because of medical complications, a nonskilled service requires the
clinical skills of a therapist in order to be safely performed, the medical
record must clearly convey the necessity for skilled services of a
therapist as opposed to the presumptive need for the skills of a family
member or aide. The medical complications and the skilled services they
require must be clearly documented in nursing or therapy notes and should
also be justified by physicians' orders.
NURSING SERVICES
Regulations in 42CFR409.33 identify services that could qualify as either
skilled nursing or skilled rehabilitation services. In a facility setting
nursing services are considered to be ancillary services that are integral
to the administration of patient care. These nursing services are not
separately billable. Riverbend will not consider services that are
typically performed by nurses (in most facilities) to require the specific
skills of an occupational therapist unless the medical record clearly
conveys the necessity for the involvement of the therapist as opposed to
the presumptive inclusion as an ancillary nursing service. In these cases the
involvement of the occupational therapist will be considered not medically
necessary even though the service itself may be medically necessary. The
following sections identify joint services in which the therapist may need
to be involved, but does not imply that specific involvement will translate
to an identifiable separately billable service.
Patient care plan development
The development, management, and evaluation of a patient care plan based on
the physician's orders constitute skilled therapy services when, because of
the patient's physical or mental condition, elements of medical care
require the involvement of a occupational therapist in order to meet the
patient's needs, promote recovery, and ensure medical safety as it relates
to conditions typically addressed by Occupational Therapists and outside
the usual expertise of registered nurses. Involvement in a care plan for
personal care services is only necessary when the aggregate of those
services requires the involvement of the therapist. An example of a
possible need for occupational therapy involvement is an aged patient with
diabetes and significant angina who is recovering from an open reduction of
a femoral neck fracture. This patient requires, among other services, a
program to restore strength and resume ambulation.
Although a nurse or properly instructed non-clinical person could perform
the individual restorative services (nutrition, activity, etc.) for this
patient, only a nurse or therapist would have the ability to understand the
inter-relationships between the services. Due to the high potential for
serious complications, such an understanding is essential to ensure the
patient's recovery and safety. Under these circumstances, the management of
the plan of care would require the skills of a nurse or therapist even
though the individual services are not typical skilled therapy services.
The need for the development of the program to restore the ability to
ambulate may involve other considerations in a complex patient. This would
be an Occupational Therapy service if the Occupational Therapist managed
the overall program in lieu of a physical therapist or if the complexities
of the program exceeded the normal post-operative return to ambulation
typically managed by the surgical nurse.
Skilled planning and management activities are not always specifically
identified in the patient's clinical record. Therefore, if the patient's
overall condition supports a finding that recovery and safety can be
ensured only if the total care is planned, managed, and evaluated by the
occupational therapist, it is appropriate to infer that skilled services
are being provided. Services performed by occupational therapists that are
specifically related to the development, management, and evaluation of a
patient care plan as outlined above may be considered reasonable and
necessary. This does not necessarily presume that the subsequent
performance of the interventions included in the plan is necessarily
reasonable and necessary or that the they are individually considered to be
skilled. It also does not imply a separately billable service as that
determination is defined by billing and coding guidelines.
Observation and assessment
Observation and assessment constitute skilled services when the skills of a
occupational therapist are required to identify and evaluate the patient's
need for modification of treatment or for additional interventions until
his or her condition is stabilized. A patient with congestive heart failure
may require observation to detect signs of decreasing cardiac compensation,
a surgical patient may require close observation for falls in the immediate
postoperative period, and patients with acute psychological symptoms may
require skilled observation to ensure their safety. However, this observation
would typically be considered a nursing service. Alternatively, the
observation or assessment of the patient specifically to determine the
safety and benefit of the occupational therapy treatment plan at any point
in time would be a medically necessary Occupational Therapy observation
service. This does not imply a separately billable service as that
determination is defined by billing and coding guidelines.
Patient education
Patient education and training services constitute a significant portion of
occupational services. These are skilled services if the occupational
therapist or occupational therapist assistant under the supervision of the
occupational therapist is necessary to teach a patient self-maintenance or
if the particular expertise of the therapist is required because the
subject matter would not normally be expected to be within the scope of the
routine patient education provided by the facility nursing service.
For example, gait training after amputation would typically require the
specialized skills of the therapist whereas assistance with ambulation
after general surgery would be within the usual scope post-operative
nursing care. Similarly, a patient with diabetic peripheral sensory
neuropathy requires instruction to learn foot-care precautions, but those
instructions can typically be provided by nursing as well as by
occupational therapy. The establishment of compensatory techniques, on the
other hand, would be beyond the typical limits of ancillary nursing care
even though many specialized nurses are quite adept at this instruction in
many post operative situations.
SPECIFIC OCCUPATIONAL THERAPY SERVICES
Ongoing assessment of rehabilitation needs and potential: Such
services are concurrent with the management of a patient care plan,
including tests and measurements of range of motion, strength, balance,
coordination, endurance, functional ability, activities of daily living,
perceptual deficits. These services are skilled services although they may
not always constitute separately billable services. That determination is
defined by billing and coding guidelines.
Therapeutic exercises: Therapeutic exercises which, because of the
type of exercises employed or the condition of the patient, must be
performed by or under the supervision of a qualified occupational therapist
to ensure the safety of the patient and the effectiveness of the treatment
may be considered to be Occupational Therapy skilled services. Therapeutic
exercises are frequently used when Occupational Therapists provide typical
physical therapy services (non task oriented exercises) but may also be
used (task oriented exercises) to help achieve a purely Occupational
Therapy goal. In this case the services are skilled when they are not
merely repetitive.
Therapeutic Activities: Therapeutic activities which, because of the
type of dynamic activities employed or the condition of the patient, must
be performed by or under the supervision of a qualified occupational
therapist to ensure the safety of the patient and the effectiveness of the
treatment are traditional Occupational Therapy skilled services.
Therapeutic activities are frequently used when Occupational Therapists
provide typical physical therapy services (non task oriented exercises) and
may sometimes be required in the early part of a therapy program in order
to prepare the patient for the demands of the occupational therapy session.
Gait evaluation and training: Gait evaluation and training furnished
to restore function in a patient whose ability to walk has been impaired by
neurological, muscular, or skeletal abnormality is a skilled service;
assistance due to general debilitation is not.
Range of motion exercises, Modalities and Personal care services:
Range of motion exercises and Modalities are frequently used by
Occupational Therapists in support of typical physical therapy goals, and
are occasionally used as part of a traditional occupational program.
Personal care services rarely meet the standards as a skilled service
within an Occupational Therapy context. The training of compensatory
techniques for personal care services is a skilled Occupational Therapy
service, but the performance of or assistance with the service itself is
not. These services are all discussed in the Physical Therapy LCD.
General and local conditioning: The general supervision of exercises
(ether general or task oriented) which have been taught to the patient;
including the actual carrying out of maintenance programs, (i.e. the
performance of the repetitive exercises required to maintain function) does
not typically require the skills of a therapist and thus does not
constitute skilled therapy services. Similarly, repetitious exercises to
improve gait, maintain or increase strength or endurance; passive exercises
to maintain range of motion in paralyzed extremities; exercises which are
not related to a specific loss of function or are performed independently
by patients; and assistive walking to increase distance as well as other
routine assistive exercises do not constitute skilled therapy services. The
skills of a occupational therapist are not medically necessary for the
provision or supervision of such exercises.
Conditioning (routine exercise) services do not require the skills of
qualified professional personnel and are not skilled services. In the
unusual instance that skilled Occupational Therapy supervision is required,
the medical record must clearly convey the necessity for the skilled
services of the therapist as opposed to the presumptive need for unskilled
assistance.
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Skilled Services
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Non-Skilled Services
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Goal is to
increase ROM, strength and function
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Goal is to maintain
ROM,
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Gait training, if
patient's ability to walk has been impaired (neuro-motor or structural
damage) and when training can be expected to significantly improve the
patient's ability to walk.
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Gait training
becomes non-skilled after the gait has been taught, when the goal is
merely to improve strength, distance or endurance, and when the service
consists primarily of assistance rather than actual neuro-motor
retraining.
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Resistive exercises,
progressive resistive exercises, neuro-development technique, are
considered skilled services.
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Active and active
assistive exercises can be given safely by a restorative or non-skilled
person, although the program may require initial development by a
therapist.
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Evaluate the
patient's needs for transfer training and design the special transfer
training technique. Provide transfer training to patient, restorative
staff and/or family
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The restorative
staff and/or family can safely and effectively perform repetitious
carrying out the transfer method after transfer.
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SPECIFIC SERVICES
Evaluation and re-evaluation guidelines
Occupational Therapy Evaluation (CPT 90003)
Evaluations are indicated prior to beginning therapy for determining the
medical necessity of initiating rehabilitative or maintenance services.
Patients must have evidence of a significant impairment that might respond
to occupational therapy in order to warrant an initial evaluation.
Initial evaluations may be covered even when it is determined as a result
of that evaluation that a skilled level of service is not required. Medical
necessity exists as long as the patient’s condition suggested a need for
the evaluation, even if the patient is not eligible for further treatment
because it is determined that further therapy would not result in any
significant improvement or that therapy would be otherwise unnecessary or
inappropriate.
The evaluation covers a complete assessment of the entire patient, not just
a single problem or system, although the focus of the assessment is the
active condition or conditions necessitating occupational therapy. It
reflects the chronicity or severity of the current problem, the possibility
of multi-site or multi-system involvement, the presence of preexisting
systemic conditions or diseases, and the stability of the condition.
Factors that influence the complexity of the evaluation process include the
clinical findings, extent of loss of function, social considerations, and
the patient’s overall function and health status. Therapists also consider
the level of the current impairments and the probability of prolonged
impairment, functional limitation, and disability; the living environment;
and the social supports (i.e., the potential for effecting an improvement
in the patient’s functional ability).
Since the initial evaluation is a comprehensive assessment, typical
clinical tests and measurements are indicated as integral parts of the
comprehensive evaluation. Separate and distinct tests and measurements are
not typically medically necessary since they are by definition unrelated.
Please refer to the descriptions of codes that describe other tests and
measurements discussed in the Physical Therapy LCD and in companion Coding
and Billing articles.
If the patient presents with multi-system involvement and/or multiple site
involvement, all areas/conditions should be assessed at the initial
evaluation (i.e., cervical pain and knee pain; low back pain and rotator
cuff; cervical pain and low back pain). Multiple initial evaluations are
not medically necessary; only one evaluation should be used to assess all
concurrent occupational therapy problems. Wheelchair evaluations, when
medically necessary, are a part of a complete therapy evaluation (i.e.
fulfilling all components as described in this section).
The initial evaluation is only medically necessary:
a)
when any provider initiates a course of treatment commencing at least 6
months after the cessation of a prior course of treatment or
b) when a new provider (i.e. new facility, not a new employee) takes over a
course of treatment following the transfer of patient care or
c) when an established provider initiates a new course of therapy for a new
pathological process.
Partial or incomplete evaluations (except when the patient experiences a
medical event that prevents the completion of the evaluation), and
evaluations not meeting the documentation requirements defined below, will
not be considered to be medically necessary. Evaluations require the skills
of the occupational therapist; evaluations performed by occupational
therapy assistants will not be considered to be medically necessary as the
level of training and expertise is not sufficient to maximize the benefit
to the patient and the authority to design the plan of care does not exist.
Initial evaluations from other therapy disciplines (e.g. Physical Therapy)
performed on the same beneficiary may also be covered, provided the
referral, evaluation, anticipated required services and plan of treatment
are not duplicative. Multiple assessments to address the same problem at
the same time are not medically necessary unless the medical record clearly
supports a need for two distinct perspectives (e.g. OT and PT) on that
problem.
Routine screening assessments and routine reassessments are not covered as
Medicare does not cover routine screening and because routine occupational
therapy screening is not medically necessary. An evaluation by a therapist
is also non-covered when the evaluation is for a non-covered service (e.g.
wheelchair ramp). Driving Assessments are non covered. In addition to the
coverage considerations, all of these instances would be not medically
necessary.
Although covered functional diagnoses are required, initial evaluations
will not typically be subject to functional or pathological diagnosis
edits; however they may be subject to other forms of review.
Occupational Therapy Re-Evaluation (CPT 97004)
The re-evaluation is a formal global assessment of patient status meeting
all the requirements of the initial evaluation. Conversely, continuous
evaluation of the patient’s progress is a component of ongoing physical
therapy services. The reassessment of ongoing therapy is considered to be a
continuous and routine aspect of any recurring intervention and is not
billed separately from the charge associated with the intervention. In the
absence of situations identified below, separate formal global
re-evaluation during an episode of care is not considered to be medically
necessary. Re-evaluations are not routinely covered solely for purposes of
updating the plan of care although the indication for a re-evaluation, a
significant change in the patient’s condition, frequently requires an
update to the plan of care following the re-evaluation.
Therapy re-evaluations are covered and may be billed as a separate charge
only if the documentation shows significant change in the patient’s
condition that supports the need to perform a formal re-evaluation of the
patient’s status. When a patient exhibits a demonstrable change in physical
functional ability, a re-evaluation is covered to reestablish appropriate
treatment goals and interventions. If a demonstrative change in a patient's
functional ability or status occurs during an episode of ongoing therapy
that warrants a wheelchair evaluation, it is covered as a part of a
complete therapy re-evaluation.
A re-evaluation is medically necessary:
a)
when there is a significant deterioration in function related to an ongoing
pathological process and an ongoing or recently completed (6 months) course
of therapy, or
b) when it is necessary to formally re-assess the patient a part of the
decision to stop therapy.
Re-evaluations require the skills of the occupational therapist;
re-evaluations performed by occupational therapy assistants will not be
considered to be medically necessary as the level of training and expertise
is not sufficient to maximize the benefit to the patient and the authority
to modify the plan of care does not exist.
General Guidelines for Therapeutic Procedures
1.
Therapeutic procedures are procedures that attempt to reduce impairments
and improve function through the application of clinical skills and/or
services The ultimate goals should be to increase functional abilities in
self-care, mobility, or patient safety.
2. Use of these procedures requires that the practitioner have direct (one
to one) patient contact.
3. Many procedures utilized by Occupational Therapists are also used by
Physical Therapists. In the interest of avoiding confusion, procedures that
are used more extensively by Physical Therapists are included in the
Physical Therapy LCD; those that are used more extensively by Occupational
Therapists are included here. Both policies are service specific, not
discipline specific. Please refer to the companion policies identified at
the beginning of this section for coverage conditions related to services
not included below.
4. Services provided concurrently by physicians, physical therapists and
occupational therapists may be covered if (and only if) separate and
distinct goals are documented in the treatment plans, the specific services
are non-overlapping, and each discipline is providing some service that is
unique to the expertise of that discipline and would not be reasonably
expected to be provided by the other disciplines.
5. Therapeutic procedures are typically effective in some clinical
situations but not in others. Therapies will be considered medically
necessary when used for diagnoses referenced in the "ICD-9 covered
diagnoses" section in this policy. Therapeutic procedures used for other
diagnoses will be considered to be not medically necessary. Medical records
used to support an initial determination or an appeal should clearly
demonstrate the requirements for coverage discussed above in order to
refute a presumption of inappropriate use in those circumstances. However,
unless specifically precluded elsewhere in this policy, non-covered
diagnoses may be overturned if the impairment requires therapy and the
medical record contains evidence that the non-covered diagnosis should be
amenable to therapy in the instance of the individual patient.
97532: Development of cognitive skills to improve attention, memory,
problem solving, (includes compensatory training), direct (one-on-one)
patient contact by the provider, each 15 minutes:
This code describes interventions used by occupational therapists to
enhance mental functions (e.g., attention, memory, perceptual, higher-level
executive, sequencing, and time functions) with conditions such as
psychiatric disorders, brain injury, and strokes to perform their
occupational roles safely and independently in their environments.
·
Cognitive skills are an important component of many occupational therapy
tasks, but the techniques used to improve cognitive functioning are
integral to the broader impairment being addressed. Cognition therapy
techniques are therefore covered as component of the traditional OT
approaches, but those services are better reported using other codes.
Cognition treatment as a single therapy, and particularly cognition therapy
used to address the goal of “improving cognition” has not been shown to be
effective in the treatment of disease or in significantly improving
outcomes. Cognition therapy alone, as coded by this CPT code, is not
covered (investigational).
· Therapies directed to improving cognition are covered and medically
necessary as a component of other coded services, and are thus reimbursable
when billed as a component of those codes.
· Treatment that is focused on restoration of functions (i.e. to know where
to locate clothes in order to get dressed) is covered as a component of the
intervention designed to improve the function. Services provided to improve
memory, billed as cognition therapy, are not covered. An evaluation to set
up a maintenance or self help program is covered.
97533: Sensory integrative techniques to enhance sensory processing and
promote adaptive responses to environmental demands, direct (one-on-one)
patient contact by the provider, each 15 minutes:
Sensory integration (SI) interventions enhance sensory processing by
persons with deficits in sensory systems (e.g., vestibular, proprioceptive,
tactile) by increasing their ability to make adaptive sensory, motor, and
behavioral responses to environmental demand. SI treatments are almost
exclusively provided to a pediatric population for conditions such as
autism, developmental disorders, ADD, CP, and motor apraxia and are rarely
considered to be medically necessary in adults. Similar techniques used in
treatment for adults, which may be considered medically necessary, are
addressed under 97112.
These
procedures are considered investigational for the treatment of adult
patients. Similar to the case with cognitive skills (above), sensory
integration is essential to task completion. It is therefore appropriate to
use sensory integrative techniques as a part of normal occupational therapy
procedures, but sensory integration as a discrete service is not medically
necessary in adults.
97535: Self-care/home management training (e.g., activities of daily
living (ADL) and compensatory training, meal preparation, safety
procedures, and instructions in use of adaptive equipment) direct one on
one contact by provider, each 15 minutes:
This procedure includes interventions to enable the performance of
activities of daily living (e.g., dressing, bathing) and instrumental
activities of daily living (e.g., meal preparation). This includes
instruction in compensatory and adaptive techniques, instruction in the use
of adaptive equipment/assistive technology, and instruction in safety
procedures and emergency responses.
·
This procedure is reasonable and necessary only when it requires the skills
of a therapist, is designed to address specific needs of the patient, and
is part of an active treatment plan directed at a specific outcome.
· The patient must have a condition for which training in activities of
daily living is reasonable and necessary, and such training must be
reasonably expected to restore or improve the functioning of the patient.
Documentation must relate the training to expected functional goals that
are attainable by the patient.
· This code should be used for activities of daily living (ADL) and
compensatory training for ADL, safety procedures, and instructions in the
use of adaptive equipment. It is not medically necessary for home
instruction of an exercise program or for assistive services.
· Only the actual time of the provider’s direct contact with the patient is
billable as reasonable and necessary. Documentation must support the number
of services/units billed each visit.
· Standard medical treatment may generally require up to 12 visits over
4 weeks. Greater than 12 visits will typically constitute a flag to
medical review to request records and review for medical necessity.
Prolonged ( > 12 visits) courses of therapy will only be considered
medically necessary when the medical record specifically identifies an
unusual condition and specifically and unambiguously specifies the need for
the total number of services provided, including the efficient use of the
earlier visits in the series.
· The patient and/or caregiver must have the capacity and willingness to
learn from instructions. The occupational therapist is expected to explain
the benefits of the instruction in order to determine that the patient is
motivated and desires to improve their level of function. Providing
treatment to a patient that has been able to verbalize that they do not
want to improve their functional level is not reasonable and necessary.
97537: Community/work reintegration (e.g., shopping, transportation,
money management, avocational activities and/or work environment
modification analysis, work task analysis, direct one on one contact by
provider, each 15 minutes:
This procedure includes interventions to enable safe and efficient
participation within the community and work environment. This includes, but
is not limited to, community mobility, financial management, environmental
analysis, and modification.
·
This training may be medically necessary when performed in conjunction with
a patient’s individual treatment plan aimed at improving or restoring
specific functions which were impaired by an identified illness or injury
and when expected outcomes that are attainable by the patient are specified
in the plan.
· This training is medically necessary only when it requires the
professional skills of a provider. Generally speaking, the professional
skills of a provider are not required to effect improvement or restoration
of function where a patient suffers a temporary loss or reduction of
function or which could reasonably be expected to improve as the patient
gradually resumes normal activities. Training that does not use techniques
specifically targeted to the impairment (i.e. when the same instruction is
equally applicable to a non-impaired individual) constitutes general
education rather than skilled therapy. General activity programs and all
activities, which are primarily social or diversional in nature, will be
denied because the professional skills of a provider are not required.
· No more than 4-6 visits (with treatment time being 30-45 minutes
in length) are typically medically necessary. Coverage beyond this time
will typically signal a need for medical review. The clinical record must
specifically and unambiguously document the unusual need for extended or
prolonged services beyond 45 minutes per day and 6 visits. More than one
hour in a given day or more than 9 visits total will be denied as not
medically necessary, although (to accommodate the patient with clearly unusual
and atypical needs) that limitation will not be binding upon appeals.
· Services which are related solely to specific employment opportunities,
work skills or work settings are not reasonable and necessary for the
diagnosis and treatment of an illness or injury and are excluded from
coverage.
97542: Wheelchair management/propulsion training, each 15 minutes:
This intervention involves training the patient in wheelchair propulsion
and safety techniques to facilitate mobility and transfers in the home or
patient’s environment. This is a training code and should involve
demonstration and instruction to the patient and/or caregiver in the use of
the wheelchair in his/her environment.
·
This procedure is considered reasonable and necessary only when it requires
the professional skills of a therapist, is designed to address specific
needs of the patient, and must be part of an active treatment plan directed
at a specific goal.
· Visits made for restraint reduction are generally non-covered.
· A total of 2-3 visits should be sufficient with visit/treatment
time being no greater than 30 minutes. Coverage beyond this level will be
denied as not medically necessary although (to accommodate the patient with
clearly unusual and atypical needs) that limitation will not be binding
upon appeals.
· Wheelchair evaluations are covered under the DME benefit and are not
separately covered for occupational therapists.
97545: Work hardening/conditioning; initial 2 hours:
97546: Work hardening/each additional hour
This intervention involves job simulation, highly structured focused tasks
and activities designed for strengthening and endurance in order to
increase work tolerance, pain tolerance, work habits and work behaviors.
Services for CPT 97545 and 97546 are related solely to employment restoring
the ability to perform work-related functions; they are therefore not
reasonable and necessary for the diagnosis or treatment of an illness or
injury.
CPT 97755 - Assistive Technology Assessment
· Provider
performs an assessment for the suitability and benefits of acquiring any
assistive technology device or equipment that will help restore, augment,
or compensate for existing functional ability in the patient (i.e.
provision of large amounts of rehabilitative engineering).
· Utilization of this service should be infrequent. An assessment is
comprehensive relative to the time period for which it is performed (i.e.
it would not be medically necessary to perform multiple assessments for the
same referral).
· This assessment is only medically necessary when performed at the
specific request of a physician who is requesting:
o
An evaluation for a specific device or class of device, OR
o A consultation regarding the availability and applicability of assistive
devices relative to a specific impairment that cannot be effectively
compensated by therapeutic measures.
· Reassessment for the same condition in the absence of a significant
change in the patient’s condition is not medically necessary.
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