Coverage for occupational therapy is determined according to individual or group customer benefits. Certain groups may apply contractual maximums.  Participating, preferred and network providers can bill the member for denied services that exceed the member's benefit limitations.

Occupational therapy is eligible for patients who meet the following criteria:

1. Meet the functional needs of a patient who suffers from physical disability due to illness, injury, congenital anomaly, or prior therapeutic intervention;
   
   
2. 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 specific, effective and reasonable treatment for the patient's diagnosis and physical condition; and
   
   
4. Is delivered by a qualified provider of occupational therapy services.

A qualified provider is one who is licensed, where required, and is performing within the scope of license.

A session is defined as up to one hour of occupational therapy (treatment and/or evaluation) on any given day.

NOTE:

An evaluation and management (E&M) service is considered an inherent part of an occupational therapy evaluation (97003-97004). The E&M service is not eligible for separate payment when reported on the same day as an occupational therapy evaluation.

Consequently, when an E&M service is reported in conjunction with an occupational therapy evaluation, the services should be combined under the appropriate code for the occupational therapy evaluation.

A participating, preferred, or network provider cannot bill the member for the E&M service.

Muscle testing (codes 95831-95834), range of motion testing (codes 95851-95852), and physical performance testing (code 97750) are considered  components of an occupational therapy evaluation (codes 97003-97004). They are not eligible for separate payment when billed with an occupational therapy evaluation.

A maintenance therapy program includes activities that maintain the patient's present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved or when no further functional progress is apparent or expected to occur.

Up to three sessions are eligible for coverage to establish an occupational therapy maintenance program. The maintenance program itself is not covered.

Occupational therapy is considered medically necessary only when provided to achieve a specific diagnosis-related goal as documented in the plan of care. For example, occupational therapy would not be considered medically necessary for the general treatment of Alzheimer disease, unless that patient also had another condition that specifically required occupational therapy.

The treatment plan should be maintained in the medical record and include the following:

• the specific modalities/procedures to be used in treatment;
• the patient's diagnosis;
• degree of severity of the problem (mild, moderate, severe);
• impairment characteristics;
• physical examination findings - x-ray or other pertinent findings;
• specific statements of long and short-term goals;
• a reasonable estimate of when the goals will be reached (estimated duration of treatment, e.g., number of weeks);
• the frequency of treatment; and,
• equipment and/or techniques utilized.

Duplicate therapy is not considered medically necessary.  For example, some patients may receive both occupational therapy and physical medicine.  In such cases, the two therapies should provide different treatments and not duplicate the same treatment.

Sensory Integration Techniques (97533)

Sensory integration techniques as a distinct and definable component of the rehabilitation process should be denied as experimental/investigational. Scientific evidence does not demonstrate the efficacy of sensory integration. A participating, preferred, or network provider can bill the member for the denied service.

Cognitive Rehabilitation (97532)

Cognitive rehabilitation is considered an eligible component of a rehabilitation program (e.g., physical medicine, speech therapy, occupational therapy) when determined to be medically necessary based on the patient's condition. However, cognitive rehabilitation performed outside of a comprehensive rehabilitation program is considered experimental/investigational. Cognitive rehabilitation performed independent of physical medicine, speech therapy, or occupational therapy is experimental/investigational because there is inadequate data published in peer reviewed literature to validate its effectiveness as a stand-alone modality. A participating, preferred, or network provider can bill the member for the denied service.

NOTE:

Occupational therapists are eligible to report procedure code 97530. Please see Medical Policy Bulletin Y-1 for information regarding this code. Occupational therapists are also eligible to report procedure codes S8950 and 97140. Please see Medical Policy Bulletin Y-11, Manual Lymphedema Drainage Therapy for information regarding these codes.

Description

Occupational therapy is the treatment of neuromusculoskeletal and psychological dysfunction, caused by disease, trauma, congenital anomaly, or prior therapeutic process, through the use of specific tasks or goal-directed activities designed to improve functional performance of the individual.

Occupational therapy services emphasize useful and purposeful activities to improve neuromusculoskeletal function and to provide training in activities of daily living (ADL). ADL include: feeding, dressing, bathing, and other self-care activities. Other occupational therapy services include: the design, fabrication and use of orthoses; guidance in the selection and use of adapted equipment; sensory-integrative and perceptual-motor activities.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Physical therapy (i.e., physical medicine) benefits may be provided for occupational therapy when care is rendered in a hospital outpatient setting by hospital based occupational therapists and it meets the FEP physical therapy criteria.

Cognitive rehabilitation (97532, 97533) is considered an eligible component of the rehabilitation process when it's determined to be medically necessary based on the patient's condition.

PRN References

12/1996, Therapeutic activities - code 97530 - to remain physical therapy service

02/1998, New physical and occupational therapy coding guidelines adopted

02/2004, Physical therapy, occupational therapy and athletic training evaluations guidelines clarified

10/2005, Blue Shield to apply occupation therapy benefits to code 97530