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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 7
Section 18.3
Occupational Therapy
Issue Date:  July 3, 1997
Authority:  32 CFR 199.4(c)(3)(x)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-62, April 22, 2020
97127, 97150, 97165 - 97168, 97533, 97535, 97799
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.
3.1  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.
Note:  See Chapter 11, Section 3.17 for occupational therapy performed by an Occupational Therapy Assistant (OTA).
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.
4.1  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.
October 28, 1997.
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