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.
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.