Occupational therapy is the treatment of neuromusculoskeletal and psycho-logical 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). Activities of daily living 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.

Payment may be made for occupational therapy in accordance with the following guidelines. The service must:

1. be performed to meet the functional needs of a patient who suffers from physical disability due to illness, injury, congenital anomaly, or prior therapeutic intervention; and

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; and

3. be considered to be specific, effective and reasonable treatment for the patient's diagnosis and physical condition; and

4. be 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:

Separate payment may not be made for an Occupational Therapy Evaluation (codes 97003-97004) and another visit rendered on the same day by the same or an affiliated provider.

Muscle testing (codes 95831-95834), Range of Motion Testing (codes 95851-95852), and Physical Performance Testing (code 97750) are considered to be components of an Occupational Therapy Evaluation (codes 97003-97004) and are not eligible for separate payment when billed with an Occupational Therapy evaluation.

A maintenance therapy program consists of activities that keep 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 eligible for coverage.

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.

Those services rendered under occupational therapy should not be duplicated by physical therapy.

Sensory integration techniques (97533) as a distinct and definable component of the rehabilitation process should be denied as investigational/experimental. Cognitive rehabilitation (97532) is considered to be an eligible component of a rehabilitation program (e.g., PT, ST, OT) when determined to be medically necessary based on the patient's condition. However, cognitive rehabilitation performed outside of a comprehensive rehabilitation program is considered investigational/experimental. Cognitive rehabilitation performed independent of PT, ST, or OT is investigational/experimental because there is inadequate data published in peer reviewed literature to validate its effectiveness as a stand-alone modality.

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 benefits may be provided for occupational therapy when care is rendered in a hospital outpatient setting by hospital based occupational therapists and meets the FEP physical therapy criteria.

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

PRN References

02/1997, Reporting 97530 for therapeutic activities
12/1996, Therapeutic activities - code 97530 - to remain physical therapy service
02/1998, New physical and occupational therapy coding guidelines adopted