Back to Top Skip to main content

Health.mil: the official website of the Military Health System (MHS) and the Defense Health Agency (DHA)

Utility Navigation Links

TRICARE Policy Manual 6010.60-M, April 1, 2015
Medicine
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-83, June 2, 2021
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 to improve, restore, or maintain function or to minimize or prevent deterioration of function of a patient is covered when prescribed and supervised by a TRICARE-authorized provider including:
•  A physician;
•  A certified Physician Assistant (PA) working under the supervision of a physician;
•  A certified Nurse Practitioner (NP); or
•  A podiatrist (see Chapter 8, Section 11.1).
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, paragraph 2.1.
4.0  EXCLUSIONS
4.1  The following occupational therapy services are not covered:
•  Vocational assessment and training.
•  General exercise programs, even if recommended by a physician (or other authorized individual professional provider acting within the scope of their license).
•  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, paragraph 2.1).
•  Range of motion and passive exercises which are not related to restoration of a specific loss of function.
4.3  Sensory integration therapy (Current Procedural Terminology (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.
4.4  Occupational therapists are not authorized to bill using Evaluation and Management (E/M) codes listed in the Physicians’ 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.
5.0  EFFECTIVE DATE
October 28, 1997.
- END -

Utility Navigation Links

DoD Seal

tricare.mil is the official website of the Defense Health Agency (DHA) a component of the Military Health System

TRICARE is a registered trademark of the Department of Defense (DoD), DHA. All rights reserved.

CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.

If you have a question regarding TRICARE benefits, please go to the TRICARE Contact Us page page.
If you need help with technical/operational issues, please go to the TRICARE Manuals Online Frequently Asked Questions page.

The appearance of hyperlinks to external websites does not constitute endorsement by the DHA of these websites or the information, products or services contained therein. For other than authorized government activities, the DHA does not exercise any editorial control over the information you may find at other locations. Such links are provided consistent with the stated purpose of this DoD website.

v4.8.7983.18738

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.