Corporate Medical Policy

Occupational Therapy Guidelines

Original Effective Date: May 2006

Revised: September 17, 2013

 

Description

Occupational therapy practice means the use of occupation and purposeful activity or intervention designed to achieve functional outcomes that promote health, wellness, prevent injury or disability and which develop, improve, sustain, or restore the highest possible level of independence of any individual who has an injury, illness, cognitive impairment, psychosocial dysfunction, mental illness, developmental or learning disability, physical disability or activity limitation or participation restriction from typical and expected life activities and roles or other disorder or condition. Occupational therapy encompasses evaluation, treatment, consultation, research, and education. Occupational therapy practice includes evaluation by skilled observation, interview, administration, and interpretation of standardized and nonstandardized tests and measurements. The occupational therapy practitioner designs and implements interventions directed toward developing, improving, sustaining, and restoring sensorimotor, neuromuscular, emotional, cognitive, or psychosocial performance components. Interventions include activities that contribute to optimal occupational performance including self-care; daily living skills; skills essential for productivity, functional communication and mobility; positioning; social integration; cognitive mechanisms; enhancing play and leisure skills; and the design, provision, and training in the use of assistive technology, devices, orthotics, or prosthetics or environmental adaptations to accommodate for loss of occupational performance. Therapy may be provided individually or in groups to prevent secondary conditions, promote community integration, and support the individual's health and wellbeing within the social and cultural contexts of the individual's natural environment.

 

Policy/Criteria

All benefits for occupational therapy services are subject to the limits and conditions in the Member's benefit plan in effect at the time services are received.

 

Benefits are available for occupational therapy services performed by licensed occupational therapy professionals according to a plan of treatment designed to restore or improve functional skills, to those who have an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction.

 

Functional skills are defined as essential activities of daily life common to all members such as dressing, grooming, feeding, swallowing, functional mobility, home management, transitions and transfers, bathing, toileting, and other life skills.

 

Benefits will be allowed for occupational therapy services performed by an occupational therapist assistant when provided according to the Occupational Therapy Practice Act Administrative Rules that apply in the state under which the therapist is licensed.

 

Habilitative Occupational Therapy is care provided within the scope of practice of an occupational therapy professional dictated by the governing state practice act for conditions, which have limited the normal age appropriate development. To be considered habilitative, functional improvement and measurable progress must be made toward achieving functional goals within a predictable period of time toward a member's maximum potential. Problems such as hearing impairment including deafness, a speech or language impairment, a visual impairment including blindness, serious emotional disturbance, an orthopedic impairment, autism spectrum disorders, traumatic brain injury, deaf-blindness, or multiple disabilities may warrant habilitative therapies.

 

Measurable progress emphasizes accomplishment of functional skills and independence in the context of the member's potential ability as specified within a care plan or treatment goals.

 

When therapy is covered:

 

To be considered eligible for coverage, occupational therapy services must meet the following criteria:

  1. Be performed to meet the functional needs of a patient who suffers from a developmental, mental illness or physical disability due to congenital anomaly, communication/swallowing disability, illness, injury, loss of body part, or prior therapeutic intervention.
  2. Be performed to achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time.
  3. Be considered by the Plan to be specific, effective and reasonable treatment for the patient's diagnosis and/or condition.
  4. Be delivered by a skilled and appropriately licensed provider of occupational therapy services.
  5. Require the judgment, knowledge and skills of a qualified occupational therapist because of the complexity and sophistication of the therapy and/or the condition of the patient.
  6. Following a sports-related injury, occupational therapy is considered a covered service up to the achievement of independent functioning in activities of daily living for the patient, subject to the limits of coverage in the Member's benefit plan in effect. Therapy services performed to further condition patients for sports activities are not covered.
  7. Re-evaluations (CPT 97004) would not be expected to be reported more frequently than every 4 weeks. A re-evaluation is to be used when the patient has not been seen for a length of time and conditions may have changed. CPT 97004 may also be reported in the case of a significant event or change in condition such as a fall or motor vehicle accident.
  8. Sensory integration (CPT 97533) is only covered when it is directly related to the member's functional daily living skills and/or self cares (i.e. dressing, hygiene, social interactions, eating/swallowing, community tolerance). This must be evident in long-term or short-term goals, otherwise, this will be deemed not medically necessary and therefore not a covered service.
  9. Services for behavioral health or mental health diagnoses will only be covered when plan of care is specific to the Member's functional daily living skills, community integration, self-cares, leisure activities, and/or social interactions. The plan of care outcomes must be specific and measurable.
  10. Manual therapy including myofascial release or lymphedema therapy may be used to achieve a desired functional outcome related to the patient's current medical diagnosis. It may be part of a total treatment program but is not covered as an individual service.
  11. A Driving Evaluation may be allowed following an acute medical condition (i.e., CVA, TBI) resulting in deficits in areas such as vision, cognition, and or motor skills.

Services will be covered for a Behind the Wheel evaluation only when services are pertaining to or directly related to use of adaptive equipment or assistive technology used to allow individuals to drive independently.

  1. Services for wound care/treatment when part of a total treatment program addressing loss of activity and engagement in typical activities of daily living.

 

What is not covered:

 

Educationally based services

Educationally based services are not covered. Specifically, programs or other services directly related to a child's ability to improve skills specific to academic outcomes.

 

Duplicate therapy

Duplicate therapy is not considered medically appropriate and necessary when provided between physical, occupational, speech or chiropratic disciplines or within the same discipline.

 

Therapeutic Massage 

When a therapeutic massage is performed with a myofascial release/soft tissue mobilization, the documentation must justify the need for both or the massage will be considered duplicative of the other service.

Ultrasound, Phonophoresis and Iontophoresis (HealthCare News #210)

Treatment with ultrasound, phonophoresis and iontophoresis is effective in pain relief, edema reduction, inflammatory conditions and tissue healing. These modalities are similar in their indications for use and their desired outcomes. It is not considered medically appropriate and necessary to use more than one of these modalities on the same injured area during the same treatment session. If more than one is utilized on the same day of treatment on different injured areas, a modifier and specific documentation is required.

 

Ultrasound with Joint Injection (HealthCare News #222)

When the physical medicine modality of ultrasound (CPT 97035) is billed with a joint injection (CPT 20600-20610), the ultrasound is being used as a method for dispersing the medication throughout the surrounding tissue. When used in this manner, ultrasound is considered not medically appropriate and necessary and will be denied as provider liable.

 

Stretch and Spray with Trigger Point Injection

Benefits are not available for a trigger point injection (CPT 20552,20553) and Stretch and Spray (CPT 97140) billed together on the same day. Trigger point injections are the most effective treatment modalities to inactivate trigger points and provide prompt relief of symptoms. Therefore, performing a Stretch and Spray in addition is not medically appropriate and necessary.

 

Maintenance

Treatment is not considered medically necessary if it does not require the skills of a qualified Occupational Therapist such as, treatment to maintain function by using routine, repetitious and reinforced procedures that are neither diagnostic nor therapeutic (i.e. ongoing ROM, strengthening activities which easily can be taught to caregivers, functional activities such as head control which is advancing at rates measured in seconds per 6 month review, etc.) or procedures that may be carried out effectively by the patient, family or caregivers at home on their own.

 

Maintenance programs such as drills, techniques and exercises that preserve the patient's present level of function and prevent regression of that function do not meet BCBSND's definition of medical necessity. Maintenance begins when the stated therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur.

Early Intensive Behavioral Intervention

Early Intensive Behavioral Intervention (EIBI) in all its forms, including Applied Behavioral Analysis (ABA), Intensive Early Interventional Behavioral Therapy (IEIBT), Intensive Early Interventional Behavioral Therapy (IEIBT), Intensive Behavioral Intervention (IBI), the Lovaas Method, Denver Model, LEAP, TEACCH, Pivotal Response Training and Discrete Trial Training

Sports Conditioning

Therapy services performed to further condition patients for sports activities are not covered.

 

Hot and cold packs (Healthcare News #216)

Hot and cold packs are considered integral to other modalities and procedures provided. The application of hot or cold packs when used alone is not covered.

 

Work Hardening Programs

No benefits are provided for work hardening/conditioning programs.

 

Hippotherapy or Equestrian Therapy (HCPCS S8940 - Equestrian/Hippotherapy, per session)

Hippotherapy/Equestrian therapy is not covered when utilized as a sole or individual treatment. S8940 (Equestrian/Hippotherapy, per session) is a per session code used to identify when the entire therapy session is hippotherapy/equestrian therapy. S8940 is a non-covered service. Therapeutic riding is not a covered service.

 

Hippotherapy/equestrian therapy may be utilized as a treatment modality as part of a member's treatment plan to work towards a clearly stated functional outcome. The appropriate therapeutic procedure code from the physical medicine and rehabilitation section of CPT should be used to describe the function being treated. One-on-one occupational therapist supervision is required when used in this manner.

 

Cranio-Sacral Therapy

Cranio-sacral therapy is a non-covered service as there is no known clear evidence based studies that support its effectiveness.

 

Driving Evaluation

A driving evaluation is not covered when resulting from the normal process of aging, diagnosis unrelated to visual, cognitive, and or motor function loss. No behind the wheel driver's training will be covered with exception of training of assistive technology or adaptive equipment.

 

Anodyne (Healthcare News #264)

Anodyne Professional Therapy System is not covered due to lack of clinical evidence indicating its impact on improved health outcomes.

Documentation Requirements:

Documentation must demonstrate medical appropriateness and necessity for occupational therapy. The treatment goals and subsequent documentation of treatment results must specifically demonstrate that occupational therapy services are contributing to such improvement. Documentation should be carried out in support of treatment goals being realized or not.

 

 

Occupational therapy documentation for the initial evaluation, treatment plan, progress notes and discharge notes should include the following information:

 

Initial Occupational Therapy Evaluation/Plan of Care:

       Diagnosis and onset date

       Name of physician if referred, date last seen by physician and next physician appointment, if applicable

       Reason for therapy referral

       Patient/Family's complaint

       Past medical history

       Any previous/current therapy

       Current and past functional abilities

       Patient's/family cognitive status (ability to learn)

       Home/work environment

       Spouse/family/caregiver ability to help if needed

       Pain scale (Example 0 to 10)

       Patient's/family goal

       Objective measurements may include but not limited to (range of motion, strength, balance, cognition, coordination, functional mobility, ADL self care)

       Short and long term goals must be functional, measurable and appropriate for the diagnosis with documented time parameters and should be directly related to objective measurement

       Treatment plan

       Specific standardized testing (age range/standardized scores)

 

Subsequent Plan of Care:

Occupational therapy treatment should be provided in accordance with an ongoing, written plan of care, completed by the occupational therapist.

 

The plan of care should be appropriate for the diagnosis, presenting symptoms and findings of the therapy evaluation.

 

The plan of care should include:

a)        Specific measurable long and short term goals

b)        A reasonable estimate of when the goals will be reached

c)         The specific modalities and/or therapeutic procedures to be used in treatment

d)        The frequency and duration of treatment.

 

The term "indefinite" should not be used as an estimate of duration.

 

The plan of care should be modified and/or revised as the patient's condition changes. This information can be documented in the progress notes.

 

Progress notes:

       Patient's current condition/complaints

       Documentation supporting the specific skilled occupational therapy intervention performed

       Patient's response to occupational therapy

       Progress towards goals

       Objective measurements

       Standardized testing (if applicable)

       Functional Living Skills which are purposeful and meaningful to patient or client

       Patient adherence to recommendations from therapy personnel

       Evidence of instruction on home exercise program and patient's compliance

       Change in Occupational Therapy plan of care if needed

       Plan for further occupational therapy

 

A progress note must be done for each patient encounter so it is clear what skilled occupational therapy intervention was performed on each date. At this time, weekly progress notes are acceptable as long as it is clear what skilled occupational therapy intervention was performed on each date of service. Flow sheets or checklists alone are not sufficient to demonstrate medical appropriateness and necessity.

 

Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information.

 

Billing and Coding

Applicable codes: Processing guidelines and payment for these services are subject to the benefit plan of the member and/or BCBSND internal medical policy guidelines.

 

CPT/HCPCS:

Evaluation

97003-97004

Modalities

97010-97039*

Therapeutic Procedures

97110-97546

Active Wound Care Mgmt

97597-97606

Tests and Measurements

97750-97755, 95831-95834, 95851-95852

Orthotic/Prosthetic Mgmt

97760-97762

Other Procedures

97799

Communication devices

92605-92606

Evaluation of swallowing

92610

Treatment of swallowing dysfunction

92526

Developmental testing

96110-96111

UB-04 Revenue Codes:

0430          

Occupational therapy

0434

Evaluation or Re-evaluation

If the code is not a time-based code, multiple units will not be allowed. Only 1 unit is allowed for codes that are not time based (e.g. 97003 - 97004) A timed based code includes a phrase similar to "each 15 minutes" in the description.

 

Providers must perform a minimum of 8 minutes of a "timed" procedure in order to bill one (1) unit.

 

*97010-97039 Physical agent modalities: Occupational therapists that submit charges utilizing CPT codes 97010-97039 must submit documentation indicating they have completed the necessary educational requirements that allow them to perform these services. Documentation in this statement is defined as a certificate indicating completion of an AOTA accredited course, state association endorsed course, or certificate from a credible provider of continuing education. Documentation not sufficient may include facility generated credentialing or training. Once initial credentialing has been approved, no further certification is required.

 

97039 should be utilized for billing fluidotherapy. Fluidotherapy is a form of dry heat treatment consisting of cellulose particles suspended in heated air that agitate around the body part.

 

97760 should not be billed on same day with specific L-codes, which indicate fitting and education is included in the fee. 97760 is appropriate to utilize if it is the only code billed for the specific orthotic or prosthetic.

 

97124 submitted with 97140 will be denied unless documentation justifies the need for both.

 

97035 submitted with 20600-20610 will be denied.

 

97140 submitted with 20552 or 20553 will be denied.

 

If modalities 97039, 97033,97035 are billed together, one will be reimbursed and the others will be denied as provider liable.

 

97010 will be bundled into the payment for the related service.

 

97150 requires that the documentation must identify the specific treatment technique used in the group, how the treatment techniques will restore function, the frequency and duration of the particular group setting, and the treatment goal in the individualized plan. The number of persons in the group must also be documented.

 

Behind the Wheel/Driving evaluation is most appropriately billed under code 97750. Training of the use of adaptive equipment or assistive technology should be submitted under 97535.

 

97755 may be utilized for assessment of assistive technology device but should be accompanied by a written report indicating specific device, medical necessity of the device and skilled intervention.

 

97545, 97546 work hardening/conditioning programs are not covered.

 

Supplies used during the course of therapy should not be billed, as they are included in the payment received for that service. Take-home supplies, exercise equipment, prosthetics or orthotics need to be billed under the appropriate revenue code and/or the corresponding HCPC code. Physical fitness equipment is not covered.

 

Source

1.       North Dakota Century Code Occupational Therapists Chapter 43-40

2.       North Dakota Occupational Therapy Association

3.      Occupational Therapy Consultant

 

Committee Review

Internal Medical Policy Committee

May 19, 2006

Internal Medical Policy Committee

February 19, 2008

Annual review. no changes

Internal Medical Policy Committee

April 16, 2009

Annual review - no changes

Internal Medical Policy Committee

April 7, 2010

Annual review. no changes

Internal Medical Policy Committee

March 16, 2011

Annual review. added "minimum of 8 minutes" required to bill1 unit

Internal Medical Policy Committee

May 30, 2013

Annual review. No changes.

Internal Medical Policy Committee

September 17, 2013

Removed preauth and IMP reference due to 2013 benefit plan rewrite. Added exclusion for EIBI.

 

 

 

Policy Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.

Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association

Noridian Mutual Insurance Company

 


Posted on: 10/17/2013