1.0 CPT
PROCEDURE CODES
97003 - 97004, 97127, 97150,
97533, 97535, 97799
2.0 DESCRIPTION
Occupational therapy is the prescribed use
of specific purposeful activity or interventions designed to promote
health, prevent injury or disability, and which develop, improve,
sustain, or restore functions which have been lost or reduced as
a result of injury, illness, cognitive impairment, psychosocial
dysfunction, mental illness, or developmental, learning or physical
disability(ies), to the highest possible level for independent functioning.
3.0 POLICY
3.1 Occupational
therapy prescribed and supervised by a physician, certified Physician
Assistant (PA) working under the supervision of a physician, or
certified Nurse Practitioner (NP) is covered.
3.2 Occupational
therapy to improve, restore, or maintain function, or to minimize
or prevent deterioration of function of a patient when prescribed
by a physician is covered in accordance with the rehabilitative
therapy provisions found in
Section 18.1.
4.0 EXCLUSIONS
4.1 The following
occupational therapy services are not covered:
• Vocational assessment
and training.
• General
exercise programs.
• Separate
charges for instruction of the patient and family in therapy procedures.
• Repetitive exercise
to improve gait, maintain strength and endurance, and assisted walking such
as that provided in support of feeble or unstable patients.
4.2 Maintenance
therapy that does not require a skilled level after a therapy program
has been designed (see
Section 18.1).
• Range
of motion and passive exercises which are not related to restoration
of a specific loss of function.
4.3 Sensory integration therapy
(CPT procedure code 97533) which may be considered a component of
cognitive rehabilitation is unproven.
Note: This policy does not exclude multidisciplinary
services, such as physical therapy, occupational therapy, or speech
therapy after traumatic brain injury, stroke and children with an autistic
disorder.
4.4 Occupational
therapists are not authorized to bill using Evaluation and Management
(E/M) codes listed in the Physicians’ Current Procedural Terminology
(CPT).
4.5 For beneficiaries
under the age of three, services and items provided in accordance
with the beneficiary’s Individualized Family Service Plan (IFSP)
as required by Part C of the Individuals with Disabilities Education
Act (IDEA), and which are otherwise allowable under the TRICARE
Basic program or the Extended Care Health Option (ECHO) but determined
not to be medically or psychologically necessary, are excluded.
4.6 For beneficiaries aged three to 21, who are
receiving special education services from a public education agency,
cost-sharing of outpatient occupational therapy services that are
required by the IDEA and which are indicated in the beneficiary’s
Individualized Education Program (IEP), may not be cost-shared except
when the intensity or timeliness of occupational therapy services
as proposed by the educational agency are not sufficient to meet
the medical needs of the beneficiary.