Occupational Therapy (OT)

Policy ID: Y-2-042

Section: Therapy

Effective Date: September 01, 2019

Revised Date: December 15, 2023

Revision Effective Date: January 01, 2024

Last Reviewed: January 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Occupational Therapy (OT) 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. OT services emphasize useful and purposeful activities to improve neuromusculoskeletal function and to provide training in activities of daily living (ADL).

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

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

Maintenance Therapy

Maintenance begins when the therapeutic goals of a treatment plan have been achieved or when no additional functional progress is apparent or expected to occur.

A maintenance program consists of activities that preserve the individual's present level of function and prevent regression of that function. These services would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness.

Maintenance therapy may be reported under physical or manipulative therapy performed for maintenance rather than restoration, and unless the individual has habilitative services benefits.

Procedure Code

S8990

Habilitative Therapy

Habilitative therapy services may be considered medically necessary when the following criteria are met:

Ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury; and
Includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

Note:

Habilitative therapy is not eligible for reimbursement, unless the member has a habilitative benefit.

Spinal manipulation is not considered a habilitative service.

Habilitative services not meeting the criteria as outlined in this policy are considered not medically necessary.

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

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

Sensory Integrative Techniques

When the member's benefit includes coverage for ASD, sensory integration is a covered service only for those individuals diagnosed with ASD.

Sensory integrative techniques as distinct and definable components of the rehabilitation process not meeting the criteria as indicated in this policy are considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Code

97533

2012 Act 90 Occupational Therapy Practice Act - July 5, 2012

Explicitly allows occupational therapists (OTs) to design, fabricate, and apply orthotics.

Procedure Codes

L3702

L3762

L3906

L3913

L3935

Taping Techniques

Taping Techniques (examples include, but are not limited to, Kinesio® Taping (kinesiology), McConnell taping techniques) are considered experimental/investigational and, therefore, non-covered. There is a lack of clinical studies showing that taping techniques to be effective.

Procedure Code

97139

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code 97533

F84.0

F84.2

F84.3

F84.5

F84.8

F84.9

Covered Diagnosis Codes for Procedure Code 97016

I87.2

I87.8

I87.9

I89.0

I97.2

M79.81

M79.89

Q82.0

R60.0

R60.1

R60.9

S70.10XA

S70.11XA

S70.12XA

S80.10XA

S80.11XA

S80.12XA

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020

Removed related reimbursement language

Review 4-1-2020 - Coding update

Added the following Procedure codes 97165, 97166, 97167, 97168, 97597 and 97598.

Internal Medical Policy Committee 3-17-2021 Annual Review

Internal Medical Policy Committee 3-23-2022 Annual Review-no criteria changed.

Internal Medical Policy Committee 7-21-2022 Revision with Coding update - Effective September 05, 2022

- Adding Procedure codes: 97016; 97033; 97113; 97150; 97161; 97162; 97163; 97164; 97546; 99339; 99340; 99374; 99375; 99377; 99378; 99380; G0181; G0182; G0237; G0238; G0239; S8948; S8950; S9123; S9124; S9125; S9128; S9129; S9131; T1021; T1025; and T1026.

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 02, 2022

Removed Procedure codes 99339 & 99340

Internal Medical Policy Committee 1-16-2024 Coding update - Effective January 01, 2024

Added procedure codes 97550, 97551, and 97552

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: Y-2-041

Section: Therapy

Effective Date: September 01, 2019

Revised Date: November 15, 2022

Revision Effective Date: January 02, 2023

Last Reviewed: November 15, 2023

Archived Date: December 31, 2023

Applies To: Commercial and Medicaid Expansion

Description

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

Maintenance Therapy

Maintenance begins when the therapeutic goals of a treatment plan have been achieved or when no additional functional progress is apparent or expected to occur.

A maintenance program consists of activities that preserve the individual’s present level of function and prevent regression of that function. These services would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness.

Maintenance therapy may be reported under physical or manipulative therapy performed for maintenance rather than restoration, and unless the individual has habilitative services benefits.

Procedure Codes

S8990

Habilitative Therapy

Habilitative therapy services may be considered medically necessary when the following criteria are met:

Ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury; and
Includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

Note:

Habilitative therapy is not eligible for reimbursement, unless the member has a habilitative benefit.

Spinal manipulation is not considered a habilitative service.

Habilitative services not meeting the criteria as outlined in this policy are considered not medically necessary.

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

Sensory Integrative Techniques

When the member's benefit includes coverage for ASD, sensory integration is a covered service only for those individuals diagnosed with ASD.

Procedure Codes

97533

2012 Act 90 Occupational Therapy Practice Act - July 5, 2012

Explicitly allows occupational therapists (OTs) to design, fabricate, and apply orthotics.

Procedure Codes

L3702

L3762

L3906

L3913

L3935

Taping Techniques

Procedure Codes

97139

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code 97533

F84.0

F84.2

F84.3

F84.5

F84.8

F84.9

Covered Diagnosis Codes for Procedure Code 97016

I87.2

I87.8

I87.9

I89.0

I97.2

M79.81

M79.89

Q82.0

R60.0

R60.1

R60.9

S70.10XA

S70.11XA

S70.12XA

S80.10XA

S80.11XA

S80.12XA

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 removed related reimbursement language

4-1-2020 Added the following Procedure codes 97165, 97166, 97167, 97168, 97597 and 97598.

Internal Medical Policy Committee 3-17-2021 Annual Review

Internal Medical Policy Committee 3-23-2022 Annual Review-no criteria changed.

Internal Medical Policy Committee 7-21-2022 Revision with Coding update - Effective September 05, 2022

Adding Procedure codes: 97016; 97033; 97113; 97150; 97161; 97162; 97163; 97164; 97546; 99339; 99340; 99374; 99375; 99377; 99378; 99380; G0181; G0182; G0237; G0238; G0239; S8948; S8950; S9123; S9124; S9125; S9128; S9129; S9131; T1021; T1025; and T1026.

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 02, 2022

Removed Procedure codes 99339 & 99340

Internal Medical Policy Committee 11-15-2023 Annual Review-no changes in criteria

Links

References (PDF)

Disclaimer

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