Aetna considers short-term occupational therapy medically necessary in selected cases when this care is prescribed by a physician, and either of the following criteria applies:
Occupational therapy services are considered medically necessary only if there is a reasonable expectation that occupational therapy will achieve measurable improvement in the member's condition in a reasonable and predictable period of time.
Once maximal therapeutic benefit has been achieved, or transition to a home program could be used for further gains, continuing supervised occupational therapy is not considered medically necessary.
Occupational therapy in persons whose condition is neither regressing nor improving is considered not medically necessary.
Aetna considers home-based occupational therapy medically necessary in selected cases based upon the member's needs (i.e., the member must be homebound). This is usually used in the transition of the member from hospital to home and is an extension of case management services.
Note: In Aetna’s HMO and QPOS plans, such home based occupational therapy accumulates towards the 60-day limit or other applicable rehabilitation benefit limits. Please check benefit plan descriptions for details.Background
Occupational therapy is a health care service that involves the use of purposeful activities to help people regain performance skills lost through injury or illness. Individual programs are designed to improve quality of life by recovering competence, maximizing independence, and prevent injury or disability as much as possible, so that a person can cope with work, home, and social life.
According to the American Occupational Therapy Association (2002), occupational therapists work with adults and children across the lifespan who may suffer from physical, developmental or psychological impairments.
Occupational therapy services emphasize useful and purposeful activities to improve neuromusculoskeletal function and to provide training in activities of daily living (ADL), including bathing, dressing, feeding, and other self-care activities. Other occupational therapy services include the design, fabrication and use of orthoses, and guidance in the selection and use of adaptive equipment.
Occupational therapy is considered medically necessary only when provided to achieve a specific diagnosis-related goal as documented in the plan of care. Occupational therapy should: (i) meet the functional needs of a patient who suffers from physical disability; (ii) achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time; (iii) be specific, effective and reasonable treatment for the patient's diagnosis and physical condition; and (iv) be delivered by a qualified provider of occupational therapy services (i.e., one who is licensed, where required, and is performing within the scope of license).
Hoffmann and colleagues (2011) examined if occupational therapy improves functional performance of basic ADL and specific cognitive abilities in people who have cognitive impairment after stroke. In this review, randomized controlled trilas (RCTs) and quasi-RCTs that evaluated an occupational therapy intervention focused on providing cognitive retraining to adults with clinically defined stroke and confirmed cognitive impairment were included. Searches up to April 2009 were conducted in: the Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, PsycBITE, OTseeker, and Dissertation Abstracts. The search also included a review of the reference lists of relevant studies, a hand-search of relevant occupational therapy journals, and contact with key researchers in the area. Two review authors independently examined the abstracts that might meet the inclusion criteria, assessed the methodological quality, and extracted data. Of 17 trials that appeared to be relevant and were reviewed in full text, only 1 trial (n = 33) was finally included in this review. The study was an RCT of cognitive skills remediation training and there was no difference between groups for the 2 outcomes that were relevant to this review that were measured: improvement in time judgement skills and improvement in basic ADLs on the Barthel Index. The effectiveness of occupational therapy for cognitive impairment post-stroke remains unclear. The potential benefits of cognitive re-training delivered as part of occupational therapy on improving basic daily activity function or specific cognitive abilities, or both, of people who have had a stroke can not be supported or refuted by the evidence included in this review. The authors stated that more research is required.
Spiliotopoulou and Atwal (2012) noted that although occupational therapists are integral to the rehabilitation process of people with amputations, the effectiveness of the occupational therapy intervention for older adults with lower limb amputations has not been investigated. These researchers examined the effectiveness of the occupational therapy interventions with older adults aged 65 years and older with lower limb amputations. A systematic search was conducted in CINAHL, PUBMED, OTSEEKER and OTDBASE from January 1985 to January 2011. The eligible papers were critiqued using a typology, which involved designation of levels of evidence and quality markers. The databases yielded 2,664 potential publications. Of these, only 2 were included in the final review. T hese studies suggested that the frequency of the occupational therapy sessions was found to be statistically significantly related to prosthesis use and that service users perceived positive benefits about the provision of stump boards. Both studies had limitations resulting in a need for further investigation in these areas. The authors concluded that research evidence on the occupational therapy interventions with this population is limited and scarce. They stated that occupational therapists need to take urgent action to address the identified evidence-based gaps in order to devise informed targeted rehabilitation programs for this client group. This systematic review has contributed to the understanding of the occupational therapy practice in the rehabilitation of older adults with lower limb amputations. It has highlighted gaps in evidence that occupational therapists need to address urgently in order to inform their rehabilitation programs with this client group.
In a meta-analysis, Kim and colleagues (2012) examined effects of occupational therapy based on sensory stimulation, environmental modification and functional task activity on the behavioral problems and depression of individual with dementia. These investigators performed an extensive search in database such as MEDLINE, CINAHL, ProQuest Medical Library, and Cochrane and occupational therapy-related 11 journals. Two reviewers independently identified studies, extracted data, evaluated methodological quality of the studies. Effect size was estimated using standardized mean difference with 95 % confidence intervals (CI). Significant heterogeneity and publication bias were investigated. A total of 9 studies including 751 people were selected. Sensory stimulation was effective intervention in improving behavioral problems (0.32; 95 % CI: 0.04 to 0.59). The authors concluded that this review identified that occupational therapy based on sensory stimulation was effective in improving behavioral problems. However, they stated that the number of studies included in this review was limited; more research is needed to enable evidence-based occupational therapy for dementia patients.
Spiliotopoulou and Atwal (2012) stated that although occupational therapists are integral to the rehabilitation process of people with amputations, the effectiveness of the occupational therapy intervention for older adults with lower limb amputations has not been investigated. These investigators examined the effectiveness of the occupational therapy interventions with older adults aged 65 years and older with lower limb amputations. A systematic search was conducted in CINAHL, PUBMED, OTSEEKER and OTDBASE from January 1985 to January 2011. The eligible papers were critiqued using a typology, which involved designation of levels of evidence and quality markers. The databases yielded 2,664 potential publications. Of these, only 2 were included in the final review. These studies suggested that the frequency of the occupational therapy sessions was found to be statistically significantly related to prosthesis use and that service users perceived positive benefits about the provision of stump boards. Both studies had limitations resulting in a need for further investigation in these areas. The authors concluded that research evidence on the occupational therapy interventions with this population is limited and scarce. They stated that occupational therapists need to take urgent action to address the identified evidence-based gaps in order to devise informed targeted rehabilitation programs for this client group.
The following care plan is required to document the medical necessity of occupational therapy:
Occupational therapy must be provided in accordance with an ongoing, written plan of care. The purpose of the written plan of care is to assist in determining medical necessity.
The plan of care must include sufficient information to determine the medical necessity of treatment. The plan of care must be specific to the diagnosis, presenting symptoms, and findings of the occupational therapy evaluation.
The plan of care must be signed by the member's attending physician and occupational therapist.
The plan of care should include:
The plan of care should be ongoing (i.e., updated as the member's condition changes) and treatment should demonstrate reasonable expectation of improvement (as defined below):
The member should be re-evaluated regularly, and there should be documentation of progress made toward the goals of occupational therapy.
The treatment goals and subsequent documentation of treatment results should specifically demonstrate that occupational therapy services are contributing to such improvement.
|CPT Codes / HCPCS Codes / ICD-9 Codes|
|CPT codes covered if selection criteria are met:|
|97003||Occupational therapy evaluation|
|97004||Occupational therapy re-evaluation|
|97140||Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes|
|97535||Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes|
|HCPCS codes covered if selection criteria are met:|
|G0129||Occupational therapy requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per day|
|G0152||Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes|
|G0160||Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective therapy maintenance program, each 15 minutes|
|S9129||Occupational therapy, in the home, per diem|
|Other HCPCS codes related to the CPB:|
|G0158||Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes|
|ICD-9 codes covered if selection criteria are met (not all-inclusive):|
|045.00 - 045.93||Acute poliomyelitis|
|138||Late effects of acute poliomyelitis|
|333.6||Genetic torsion dystonia|
|333.71 - 333.79||Acquired torsion dystonia|
|335.20||Amyotrophic lateral sclerosis|
|335.21||Progressive muscular atrophy|
|343.0 - 343.9||Infantile cerebral palsy|
|741.00 - 741.93||Spina bifida|
|V57.21||Encounter for occupational therapy [when home program could be used for further gains or condition is neither regressing nor improving]|
|ICD-9 codes not covered for plans that exclude developmental delay:|
|314.1||Hyperkinesis with developmental delay|
|315.00 - 315.9||Specific delays in development|
|317 - 319||Mental retardation|
|781.3||Lack of coordination|
|783.40||Lack of normal physiological development, unspecified|
|784.61||Alexia and dyslexia|
|V40.0||Problems with learning|
|V40.1||Problems with communication (including speech)|