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
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
(SIT) (Current
Procedural Terminology (CPT) procedure code 97533)
is
unproven.
SIT services
are not payable separately or when billed in conjunction with other
therapies. For example: SIT services provided during an otherwise
covered multidisciplinary therapeutic intervention or service; during
physical therapy, occupational therapy, or speech therapy; or as
a component of cognitive rehabilitation, are services for which
TRICARE bundles payment into the payment for other related services.
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.