Criteria
Coverage is subject to the specific terms of the member's benefit plan.
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 |
| 97535 | 97537 | 97542 | 97545 | 97546 | 97550 | 97551 |
| 97552 | 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 |
