1.0 CPT PROCEDURE
CODES
97127, 97150, 97165
- 97168, 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.