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Occupational Therapy - CAM 80303HB

Description:
Occupational therapy (OT) is a form of rehabilitation therapy involving the treatment of neuromusculoskeletal and psychological dysfunction through the use of specific tasks or goal-directed activities designed to improve the functional performance of an individual.

Occupational therapy involves cognitive, perceptual, safety and judgment evaluation and training. These services emphasize useful and purposeful activities to improve neuromusculoskeletal functions 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, and guidance in the selection and use of adapted equipment.

Policy:
Occupational therapy services are considered MEDICALLY NECESSARY when performed to treat the needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies or prior therapeutic intervention.

Occupational therapy services must meet all of the following criteria:

  • Meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies or prior therapeutic intervention.
  • 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.
  • Provide specific, effective and reasonable treatment for the patient’s diagnosis and physical condition.
  • Be delivered by a qualified provider of occupational therapy services. A qualified provider is one who is licensed where required and performs within the scope of licensure.
  • Require the judgment, knowledge and skills of a qualified provider of occupational therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient.

Occupational therapy sessions are typically defined up to one hour of OT provided on a given day. Sessions may include:

  • Basic activities of daily living and self-care training.
  • Higher level independence living skills instruction.
  • Functionally oriented upper extremity exercise programs.
  • Cognitive, perceptual, safety and judgment evaluations and training.
  • Upper extremity orthotic and prosthetic programs.
  • Training of the patient and family in home exercise programs.

A plan of care should include:

  • Specific statements of long- and short-term goals.
  • Measurable objectives.
  • A reasonable estimate of when the goals will be reached.
  • The specific treatment techniques and/or activities to be used in treatment.
  • The frequency and duration of treatment.

Non-Skilled Services:
There are certain types of treatments that do not generally require the skills of a licensed, qualified OT provider and are therefore NOT MEDICALLY NECESSARY. Such services may include:

  • Passive range of motion (ROM) treatment, which is not related to the restoration of a specific loss of function.
  • Services that maintain function by using routine, repetitive and reinforced procedures (e.g., daily feeding program once the adaptive procedures are in place).

PLEASE SEE SPECIFIC CONTRACT VERBIAGE FOR EXCLUSIONS, LIMITATIONS AND/OR MAXIMUMS RELATED TO PHYSICAL THERAPY.

NOTE: Homebound status is defined as an individual who normally would be able to leave the home, however, due to illness or injury, leaving the home will now require considerable and taxing effort. An aged person who does not travel from his or her home because of feebleness and insecurity brought on by advanced age is NOT considered homebound.

PLEASE SEE CAM 191HB MEDICAL RECORDS DOCUMENTATION STANDARDS.

Rationale:
A search of literature was completed through the MEDLINE database for the period of January 1987 through Oct. 26, 1995. The search strategy focused on references containing the following medical subject heading:

  • Occupational Therapy (including review or clinical trial or practice guidelines or meta-analysis)

See Also:

  • Physical Therapy Medical Policy 80302
  • Speech Therapy Medical Policy 80304.

Documentation Requirements:
Provider Record-Keeping Requirements for Modalities and Therapeutic Procedures
Definitions

  • Modality/Modalities: Current Procedural Terminology (CPT) codes 97010 through 97039.
  • Therapeutic Procedure(s): CPT codes 97110 through 97564.
  • Timed Codes: Those modalities and therapeutic procedures that contain the phrase "each 15 minutes" in their code descriptors. For example, CPT code 97110 is a timed code. The descriptor for CPT code 97110 reads: "Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility."

General Requirements:
Providers must maintain medical records that comport with the record-keeping standards of their profession. However, to the extent the provider’s profession’s record-keeping standards do not already require it, for a provider to be reimbursed for claims for modalities and/or therapeutic procedures, his or her medical records must also comply with the following requirements: 

  1. The date and the patient’s name must appear on each page of the patient’s medical records.
  2. Each patient encounter must be a separate record.
  3. The patient’s entire record must be legible (i.e., must be legible to someone other than the writer).
  4. Entries in the medical record must be made within a week of the provider performing the modalities and/or therapeutic procedures.
  5. The medical record must demonstrate that the modalities and/or therapeutic procedures are medically necessary.
  6. The medical records must demonstrate that the patient’s treatment plan is consistent with his or her diagnoses.
  7. CPT codes and ICD codes reported on claim forms or billing statements are supported by the documentation in the medical record.
  8. The provider must provide a definition sheet of abbreviations specific to his or her office to assist this health plan in interpreting patients’ medical records.
  9. Documentation corrections should be a single line drawn through the error, with the corrected text in close proximity, initialed and dated by the person who made the error.

Treatment Notes/Patient Encounter Notes
In addition, to the extent the provider’s profession’s record-keeping standards do not already require it, for a provider to be reimbursed for claims for modalities and/or therapeutic procedures, the following information must be recorded by the provider in each individual record of a patient encounter.

  1. A description, not a reiteration of the CPT code, of each individual modality and therapeutic procedure provided and billed in language that can be compared with the billing on the claim to verify correct coding
  2. For timed codes, an indication of the total number of minutes each individual modality and therapeutic procedure was performed
  3. A description of the specific area of the patient’s body to which each individual modality and therapeutic procedure was directed and/or performed
  4. The legible signature and professional identification of the individual who furnished each individual modality or therapeutic procedure. (This health plan does not recognize incident-to billing, but requires that claims be billed under the name of the provider who actually rendered the service, modality or therapeutic procedure.)
  5. The patient’s response to the treatment
  6. A skilled ongoing reassessment of the patient’s progress toward treatment goals
  7. A description of the patient’s progress toward the goals in objective, measurable terms using consistent and comparable methods
  8. A description of any patient problems or changes to the plan of care
  9. A description of the reason for the encounter
  10. A date for a return visit or follow-up plan

Coding Section

Codes Number Description
CPT 97003

Occupational therapy evaluation
  97004 Occupational therapy re-evaluation
  97165 (effective 1/1/2017) 

Occupational therapy evaluation, low complexity, requiring these components:

  • An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem;
  • An assessment(s) that identifies 1 – 3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessments(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.

Typically, 30 minutes are spent face-to-face with the patient and/or family.  
  97166 (effective 1/1/2017) 

Occupational therapy evaluation, moderate complexity, requiring these components:

  • An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical cognitive, or psychosocial history related to current functional performance;
  • An assessment(s) that identifies 3 – 5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.

Typicall, 45 minutes are spent face-to-face with the patient and/or family.
  97167 (effective 1/1/2017) 

Occupational therapy evaluation, high complexity, requiring these components:

  • An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance;
  • An assessment(s) that identifies 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
  • Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient present with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.

Typically, 60 minutes are spent face-to-face with the patient and/or family. 
  97168 (effective 1/1/2017) 

Re-evaluation of occupational therapy established plan of care, requiring these components:

  • An assessment of changes in patient functional or medical status with revised plan of care.
  • An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and
  • A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.

Typically, 30 minutes are spent face-to-face with the patient and/or family. 
  97535 Self-care/home management training (e.g., activities of daily living and compensation training, meal preparation, safety procedures and instructions in use of assistive technology devices/adaptive equipment) direct-one-on one contact by provider, each 15 minutes
ICD-9 Procedure 93.83 Occupational therapy
ICD-9 Diagnosis   Code applicable conditions
HCPD G0152 Services performed by a qualified occupational therapist in 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 (new code 01/01/11)
  G160 Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective therapy maintenance program, each 15 minutes (new code 01/01/11)
  S9129 Occupational therapy, in the home, per diem
ICD-10-CM (effective 10/01/15)   Code applicable conditions
ICD-10-PCS (effective 10/01/15)   ICD-10-PCS codes are only used for inpatient services. The following code ranges are available for occupational therapy services provided inpatient.
  F08- Physical rehabilitation, activities of daily living treatment, code range
Type of Service Medical  
Place of Service Inpatient/Outpatient/Occupational Therapist's Office  
Modifiers    Effective 01/01/2018, the following modifiers should be used to denote if the services rendered are habilitative or rehabilitative:
  96 (effective 1/1/2018)  Habilitative Services
  97 (effective 1/1/2018)  Rehabilitative Services

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2024 Forward     

08/13/2024 Removing the following statement REMINDER: BlueCross BlueShield of South Carolina does not recognize incident-to-billing but requires that claims be billed under the name of the provider who actually rendered the service, modality or therapeutic procedure. 

06/27/2024 Annual review, no change to policy intent 

01012024  NEW POLICY

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