Criteria
OT may be considered medically necessary for individuals who meet ALL of the following criteria:
- The therapy is aimed at improving, adapting or restoring functions of an individual who has been impaired or permanently lost as a result of physical disability due to illness, injury, congenital anomaly, or prior therapeutic intervention; and
- Achieve a specific diagnosis-related goal for an individual who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time based on the qualified OT assessment of the individual’s restoration potential and unique medical condition; and
- Specific, effective and reasonable treatment for the individual’s diagnosis and physical condition; and
- The services are delivered by a qualified provider of OT services.
A qualified provider is an individual who is licensed, where required, and performs within the scope of licensure.
A typical treatment plan consists of up to one (1) hour sessions and up to four (4) physical medicine procedures per date of service and includes ANY of the following:
- Modalities; or
- Therapeutic procedures; or
- Tests and measurements; or
- Muscle range of motion (ROM) testing; or
- Orthotic management and prosthetic management.
Exceptions include standardized cognitive performance testing per hour and work hardening/conditioning; initial two (2) hours.
Each additional hour of work hardening/conditioning will be considered exceeding the limitation; and is considered not medically necessary.
No other physical medicine procedure codes can be billed on the same date of service.
Duplicate therapy is considered not medically necessary. Example: An individual receiving therapy services from two (2) different providers treating the same condition.
Procedure Codes
| 4018F |
90901 |
95851 |
95852 |
95992 |
96125 |
97012 |
| 97014 |
97016 |
97018 |
97022 |
97024 |
97026 |
97028 |
| 97032 |
97033 |
97034 |
97035 |
97036 |
97039 |
97110 |
| 97112 |
97113 |
97116 |
97124 |
97129 |
97130 |
97139 |
| 97140 |
97150 |
97161 |
97162 |
97163 |
97164 |
97530 |
| 97533 |
97535 |
97537 |
97542 |
97545 |
97546 |
97750 |
| 97755 |
97760 |
97761 |
97763 |
97799 |
99374 |
99375 |
| 99377 |
99378 |
99380 |
G0181 |
G0182 |
G0237 |
G0238 |
| G0239 |
G0283 |
S8948 |
S8950 |
S9123 |
S9124 |
S9125 |
| S9128 |
S9129 |
S9131 |
T1021 |
T1025 |
T1026 |
