Clinical UM Guideline
|Guideline #:||CG-REHAB-05||Current Effective Date:||06/28/2016|
|Status:||Revised||Last Review Date:||05/05/2016|
This document addresses occupational therapy (OT) services, skilled services which may be delivered by an occupational therapist or other health care professional acting within the scope of a professional license. OT is used for both rehabilitation and habilitation.
Rehabilitative services are intended to improve, adapt or restore functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality involving goals an individual can reach in a reasonable period of time. Benefits will end when treatment is no longer medically necessary and the individual stops progressing toward those goals.
Habilitative services are intended to maintain, develop or improve skills needed to perform activities of daily living (ADLs) or instrumental activities of daily living (IADLs) (see definitions) which have not (but normally would have) developed or which are at risk of being lost as a result of illness, injury, loss of a body part, or congenital abnormality. Examples include therapy for a child who is not walking at the expected age.
Note: The availability of rehabilitative and/or habilitative benefits for these services, state and federal mandates, and regulatory requirements should be verified prior to application of criteria listed below. Benefit plans may include a maximum allowable occupational therapy benefit, either in duration of treatment or in number of visits. When the maximum allowable benefit is exhausted, coverage will no longer be provided even if the medical necessity criteria described below are met.
Note: Please see the following related document for additional information:
Rehabilitative occupational therapy (OT) services are considered medically necessary when ALL the following criteria are met:
*Note: Illness includes a wide range of conditions. For purposes of clarity, illness includes, but is not limited to autism spectrum disorder.
Not Medically Necessary:
Maintenance (see definitions) therapy is considered not medically necessary as a rehabilitative service.
Rehabilitative OT services are considered not medically necessary if any of the following is determined:
Duplicate rehabilitative therapy is considered not medically necessary. When individuals receive physical, occupational, or speech therapy, the therapists should provide different treatments that reflect each therapy discipline's unique perspective on the individual's impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals.
Habilitative OT services are considered medically necessary when ALL the following criteria are met:
*Note: Illness includes a wide range of conditions. For purposes of clarity, illness includes, but is not limited to, autism spectrum disorder.
Not Medically Necessary:
Habilitative OT services are considered not medically necessary if any of the following is determined:
Duplicate habilitative therapy is considered not medically necessary. When individuals receive physical, occupational, or speech therapy, the therapists should provide different treatments that reflect each therapy discipline's unique perspective on the individual's impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals.
A comprehensive evaluation is essential to determine if OT services are medically necessary, gather baseline data, establish a treatment plan, and develop goals based on the data. The initial evaluation is usually completed in a single session. An evaluation is needed before implementing any OT treatment. Evaluation begins with the administration of appropriate and relevant assessments using standardized assessments and tools. The evaluation must include:
An occupational therapy session can vary from fifteen minutes to four hours per day; however, treatment sessions lasting more than one hour per day are rare in outpatient settings. Treatment sessions for more than one hour per day may be medically appropriate for inpatient acute settings, day treatment programs, and select outpatient conditions, but must be supported in the treatment plan and based on an individual's medical condition. These sessions may include:
Documentation of treatment sessions must include:
In order to reflect that continued OT services are medically necessary, intermittent progress reports must demonstrate that the individual is making functional progress. Progress reports should include at a minimum:
A reevaluation is usually indicated when there are new significant clinical findings, a rapid change in individual's status, or failure to respond to occupational therapy interventions. There are several routine reassessments that are not considered reevaluations. These include ongoing reassessments that are part of each skilled treatment session, progress reports, and discharge summaries.
Reevaluation is a more comprehensive assessment that includes all the components of the initial evaluation, such as:
Providers of OT Services
The services are delivered by a qualified provider of occupational therapy services who is certified, licensed, or otherwise regulated by the State or Federal governments. Occupational therapy assistants may provide services under the direction and supervision of an occupational therapist. Benefits for services provided by these practitioners are dependent upon the member's contract language.
Aides, athletic trainers, exercise physiologists, life skills trainers, and rehabilitation technicians do not meet the definition of a qualified practitioner regardless of the level of supervision. Aides and other nonqualified personnel as listed above are limited to non-skilled services such as preparing the individual, treatment area, equipment, or supplies; assisting a qualified therapist or assistant; and transporting individuals. They may not provide any direct member treatments, modalities, or procedures.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|92605||Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour|
|92618||Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes|
|92606||Therapeutic service(s) for the use of non-speech-generating device, including programming and modification|
|92607-92608||Evaluation for prescription for speech-generating augmentative and alternative communication device|
|92609||Therapeutic services for the use of speech-generating device, including programming and modification|
|92610||Evaluation of oral and pharyngeal swallowing function|
|92611||Motion fluoroscopic evaluation of swallowing function by cine or video recording|
|94667||Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation|
|94668||Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent|
|97003||Occupational therapy evaluation|
|97004||Occupational therapy re-evaluation|
|97010-97028||Application of a modality to one or more areas (supervised) [includes codes 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028]|
|97032-97036||Application of a modality to one or more areas (constant attendance) [includes codes 97032, 97033, 97034, 97035, 97036]|
|97039||Unlisted modality [when not specified as a procedure that is considered investigational and not medically necessary]|
|97110-97139||Therapeutic procedure, one or more areas [includes codes 97110, 97112, 97113, 97116, 97124, 97139]|
|97140||Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes|
|97150||Therapeutic procedure(s), group (2 or more individuals)|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes|
|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, each 15 minutes|
|97537||Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment) direct one-on-one contact, each 15 minutes|
|97542||Wheelchair management (eg, assessment, fitting, training), each 15 minutes|
|97597-97598||Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session|
|97602||Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session|
|97750||Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes|
|97755||Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes|
|97760||Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes|
|97761||Prosthetic training, upper and/or lower extremity(s), each 15 minutes|
|97762||Checkout for orthotic/prosthetic use, established patient, each 15 minutes|
|97799||Unlisted physical medicine/rehabilitation service or procedure [when not specified as a procedure that is considered investigational and not medically necessary]|
|G0129||Occupational therapy requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per session (45 minutes or more)|
|G0152||Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes|
|G0158||Services performed by a qualified occupational therapist assistant in the home health or hospice 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 occupational therapy maintenance program, each 15 minutes|
|G0281||Electrical stimulation, (unattended), to one or more areas, for chronic Stage III and Stage IV pressure ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care|
|G0282||Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281|
|G0283||Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care|
|G0295||Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses|
|G0329||Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, and diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care|
|S8950||Complex lymphedema therapy, each 15 minutes|
|S8990||Physical or manipulative therapy performed for maintenance rather than restoration|
|S9129||Occupational therapy, in the home, per diem|
|Note: HCPCS modifier '-SZ' may be used with the above procedure codes to indicate 'habilitative services'|
Activities of daily living (ADLs): Self-care activities such as transfers, toileting, grooming and hygiene, dressing, bathing, and eating.
Instrumental activities of daily living (IADLs): Activities related to independent living and include preparing meals, managing money, shopping, doing housework and using a telephone; IADLs do not involve personal care activities.
Maintenance treatments: Services intended to preserve the individual's present level range, strength, coordination, balance, pain, activity, function, etc. and prevent regression of the same parameters. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur.
Qualified provider of occupational therapy services: One who is licensed where required and performs within the scope of licensure.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
OT (Occupational Therapy)
|Revised||05/05/2016||Medical Policy & Technology Assessment Committee (MPTAC) review. Defined abbreviation in rehabilitative NMN section. Updated references. Removed ICD-9 codes from Coding section.|
|Reviewed||05/07/2015||MPTAC review. Updated Coding, Description and References.|
|Revised||11/13/2014||MPTAC review. Clarified medically necessary criteria for habilitative services. Clarified note for rehabilitative and habilitative therapy. Updated References.|
|Revised||05/15/2014||MPTAC review. Clarified medically necessary criteria for rehabilitative OT services. Revised medically necessary criteria to address habilitative OT services. Clarified not medically necessary criteria for rehabilitative OT services; duplicate rehabilitative therapy and maintenance therapy. Revised not medically necessary criteria to address habilitative OT services. Updated Description, Definitions, References and Websites. Updated coding section with HCPCS modifier '-SZ' effective 07/01/2014.|
|Reviewed||02/13/2014||MPTAC review. Websites and Coding updated.|
|Reviewed||08/09/2012||MPTAC review. References and Websites updated.|
|01/01/2012||Updated Coding section to include 01/01/2012 CPT changes; removed revenue codes 0430-0439.|
|Reviewed||08/18/2011||MPTAC review. References and Websites updated.|
|01/01/2011||Updated Coding section with 01/01/2011 CPT and HCPCS changes.|
|Reviewed||08/19/2010||MPTAC review. Websites and references updated.|
|01/01/2010||Updated Coding section with 01/01/2010 HCPCS changes.|
|Reviewed||08/27/2009||MPTAC review. Removed Place of Service/Duration. References and coding updated.|
|Reviewed||08/28/2008||MPTAC review. References updated.|
|Reviewed||08/23/2007||MPTAC review. Coding section updated.|
|Revised||09/14/2006||MPTAC review. Minor revision to Not Medically Necessary statement. References updated. Coding updated: removed CPT 97504, 97520, 97703 deleted 12/31/05 (see historical document).|
|Revised||12/01/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
Last Review Date
|RA-008 (Midwest Medical Review & UM criteria)||Physical Therapy / Occupational Therapy For NASCO, Prestandardized Medicare Supplement Plans, Group Blue Retiree Products, and FEP|
|WellPoint Health Networks, Inc.|