1.0 CPT 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 The contractor
shall cover occupational therapy to improve, restore or maintain
function or to minimize or prevent deterioration of function of
a patient when prescribed and supervised by a TRICARE-authorized provider.
Authorized providers include:
• Physicians;
• Certified Physician Assistants
(PAs) working under the supervision of a physician;
• Certified Nurse Practitioners
(NPs); or
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,
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).
4.3 Range
of motion and passive exercises which are not related to restoration
of a specific loss of function.
4.4 Sensory
integration therapy (Current Procedural Terminology (CPT) 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.
4.5 Occupational therapist claims
using Evaluation and Management (E/M) codes listed in the Physicians
CPT. The contractor shall reject these claims.
4.6 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.
4.7 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.