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.