Occupational Therapy


	UM Guidelines

Rehabilitative Care

BlueCross BlueShield of Tennessee developed this guideline to supplement the Milliman Care Guidelines®

BCBST modification effective June 26, 2008*

Added:

Exceptions may be required to comply with EPSDT & TennCare regulations.

Homebound status applies to therapy services (physical therapy, occupational therapy, and speech therapy) when provided in the home setting.

See also Medical Policy titled: Speech / Language Therapy, Occupational Therapy and Physical Therapy for Autism.

Description of Occupational Therapy

Occupational therapy (OT) is a medically prescribed treatment concerned with improving or restoring functions that have been impaired by illness, injury or disability through the use of specific tasks or goal-directed activities designed to improve the functional performance of an individual.

Occupational therapy provides training in the activities of daily living (ADL) & improves neuromusculoskeletal functions. Occupational therapy can also include the design, fabrication & use of orthoses, & guidance in the selection & use of adapted equipment.

Occupational Therapy Criteria

If a covered benefit, may be approved for members with ALL of the following:

Performed by or under the direct supervision of a licensed occupational therapist with a physician order.

In the outpatient setting, a certified / licensed therapy assistant under the direct supervision of a licensed occupational therapist may render services. A qualified therapist must be physically present & actively involved in the treatment. Refer to the medical policy Staff Supervision Requirements for Delegated Services for further information regarding BCBST's supervision requirements.

Under extenuating circumstances (e.g., network inadequacy in rural areas) a licensed / certified therapy assistant may render services through a home health provider in the home health setting under the general supervision of a licensed therapist. Under these conditions, a licensed therapist must evaluate the patient, develop a treatment plan, and implement the plan. General supervision requires initial direction and periodic re-evaluation of the patient by the registered therapists; however, the supervisor does not have to be physically present or on the premises. Refer to the medical policy Staff Supervision Requirements for Delegated Services for further information regarding BCBST's supervision requirements.

Services must be performed by a certified occupational therapist licensed in the state they are practicing.

Prescribed by a physician to achieve a diagnosis-related goal as documented in the plan of care.

Appropriate for the treatment of the individual's illness or injury.

Performed to treat the needs of a patient suffering physical impairment due to disease, trauma, congenital anomalies, or prior therapeutic intervention.

Services rendered must be directly related to a written treatment plan that includes goals as approved by the attending physician.

Reasonable expectation must exist that the therapy will result in a significant practical improvement in the level of functioning within a reasonable period of time.

Progress must be objectively measurable with progress toward goals established in evaluation.

Services must be considered acceptable standards of medical practice that are specific to the treatment of the patient's condition.

Occupational Therapist must sign all documentation (notes & evaluations)

Documented plan of care & evaluation that includes specific criteria, as noted in this guide, must be submitted.

Patient &/or caregiver compliance, cooperation, & ability to comprehend are consistent with the written treatment regimen & goals.

Patient must be making reasonable progress.

Services rendered must include instruction to patient & family / caregiver that include teaching of home program.

Services rendered must require the skills of a qualified provider of occupational therapy services.

The evaluation should demonstrate actual hands-on assessment occurred as opposed to a limited screening assessment.

Reevaluation/reexamination is the process by which an individual’s status is updated following the initial examination. A reevaluation/reexamination must meet the following requirements:

The reevaluation/reexamination is performed because of:

New clinical indications; or

Failure to respond to interventions; or

Failure to establish progress from baseline data.

The reevaluation/reexamination must be precertified by BCBST.

Documentation should be specific as to the patient's ability to retain instruction & follow directions to preserve safety.

The focus of therapy should be on activities the patient needs within their living environment.

Activities of daily living include self maintenance tasks, but are not limited to:

Grooming

Oral hygiene

Bathing, showering

Toilet hygiene

Dressing

Feeding / eating

Functional mobility

Home management activities include, but are not limited to:

Meal preparation & clean up

Safety procedures

Household maintenance

Teaching of compensatory techniques to improve the level of independence should be conducted in conjunction with therapy.

Limitations (Services not covered)

For treatment of temporary loss or reduction of function (i.e., temporary weakness associated with prolonged rest following major surgery) that would be expected to improve spontaneously with increased normal activity.

Enhancement therapy that is designed to improve a patient's condition beyond normal variation in individual development & aging.

Occupational Therapy should not be duplicated by Physical Therapy. When occupational therapy & physical therapy are both being received, the therapies should provide different treatments with separate treatment plans & goals.

Performance impairments identified during assessment that are not associated with any current or potential functional limitations are to be excluded from the treatment plan.

Palliative services as opposed to restorative services that improve function.

Orthotic training for use of an orthotic device that is included in the cost of an orthotic device.

Activities or programs that are primarily social or diversional in nature.

Range of motion & passive exercise not related to restoration of a specific loss of function.

Maintenance beyond establishment of a home program. Maintenance therapy is used to delay or minimize muscular deterioration in chronic disease.

A maintenance program consists of activities that preserve the patient's present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved or when no additional functional progress is apparent or expected to occur. Occupational therapy required to delay or minimize muscular deterioration for patients suffering from a chronic disease should also be considered maintenance therapy.

Assessment Requirements (Evaluation & Plan of Care)

Evaluation

Ordering MD & last visit

Primary diagnosis

Date of diagnosis onset

Baseline status / current abilities

Functional potential

Prior level of functioning

Diagnostic & assessment services used to ascertain the type, causal factors, & severity of dysfunction or disorders.

Support system

Developmental delays

Other therapies or treatments

Patient's goals

Medical compliance

Prior occupational therapy received & outcome
Plan of Care

Long & short-term goals

Discharge goals

Measurable objectives

Functional objectives

Home program

Duration of therapy

Frequency of therapy

Dates of service

Specific modalities & therapy

Authorization of Services

A limited number of sessions should be authorized initially (i.e., up to 3 times a week for 2 weeks).

Greater than 3 visits per week is seldom justified, exceptions must be based on review of both attending physician & OT documentation.

Extension requires reevaluation. Evaluation should include the following:

Progress being made, level of cooperation, compliance, address DC plans & DC date.

Date of last physician visit for this treatment & date extension ordered.

Sources

BlueCross BlueShield of Tennessee network physicians. April - June 2008.

* These guideline(s) have been revised from the Milliman USA Milliman Care Guidelines. The portions of the guideline(s) which have been revised are identified through the use of [insert: italic, boldface, underlined, etc. as appropriate] text, and Milliman USA has neither reviewed nor approved the modified material. Any statement to the contrary or association of the modified material with Milliman USA is strictly prohibited. This document has been classified as public information.

The above information only contains the modified portion of the Milliman Care Guideline. If you wish to view the complete Milliman Care Guideline, please contact Milliman USA.

	Added:


	*Exceptions may be required to comply with EPSDT & TennCare regulations. Homebound status applies to therapy services (physical therapy, occupational therapy, and speech therapy) when provided in the home setting.*

	See also Medical Policy titled: Speech / Language Therapy, Occupational Therapy and Physical Therapy for Autism.

	Description of Occupational Therapy Occupational therapy (OT) is a medically prescribed treatment concerned with improving or restoring functions that have been impaired by illness, injury or disability through the use of specific tasks or goal-directed activities designed to improve the functional performance of an individual. Occupational therapy provides training in the activities of daily living (ADL) & improves neuromusculoskeletal functions. Occupational therapy can also include the design, fabrication & use of orthoses, & guidance in the selection & use of adapted equipment. Occupational Therapy Criteria If a covered benefit, may be approved for members with ALL of the following: Performed by or under the direct supervision of a licensed occupational therapist with a physician order. In the outpatient setting, a certified / licensed therapy assistant under the direct supervision of a licensed occupational therapist may render services. A qualified therapist must be physically present & actively involved in the treatment. Refer to the medical policy Staff Supervision Requirements for Delegated Services for further information regarding BCBST's supervision requirements. Under extenuating circumstances (e.g., network inadequacy in rural areas) a licensed / certified therapy assistant may render services through a home health provider in the home health setting under the general supervision of a licensed therapist. Under these conditions, a licensed therapist must evaluate the patient, develop a treatment plan, and implement the plan. General supervision requires initial direction and periodic re-evaluation of the patient by the registered therapists; however, the supervisor does not have to be physically present or on the premises. Refer to the medical policy Staff Supervision Requirements for Delegated Services for further information regarding BCBST's supervision requirements. Services must be performed by a certified occupational therapist licensed in the state they are practicing. Prescribed by a physician to achieve a diagnosis-related goal as documented in the plan of care. Appropriate for the treatment of the individual's illness or injury. Performed to treat the needs of a patient suffering physical impairment due to disease, trauma, congenital anomalies, or prior therapeutic intervention. Services rendered must be directly related to a written treatment plan that includes goals as approved by the attending physician. Reasonable expectation must exist that the therapy will result in a significant practical improvement in the level of functioning within a reasonable period of time. Progress must be objectively measurable with progress toward goals established in evaluation. Services must be considered acceptable standards of medical practice that are specific to the treatment of the patient's condition. Occupational Therapist must sign all documentation (notes & evaluations) Documented plan of care & evaluation that includes specific criteria, as noted in this guide, must be submitted. Patient &/or caregiver compliance, cooperation, & ability to comprehend are consistent with the written treatment regimen & goals. Patient must be making reasonable progress. Services rendered must include instruction to patient & family / caregiver that include teaching of home program. Services rendered must require the skills of a qualified provider of occupational therapy services. The evaluation should demonstrate actual hands-on assessment occurred as opposed to a limited screening assessment. Reevaluation/reexamination is the process by which an individual’s status is updated following the initial examination. A reevaluation/reexamination must meet the following requirements: The reevaluation/reexamination is performed because of: New clinical indications; or Failure to respond to interventions; or Failure to establish progress from baseline data. The reevaluation/reexamination must be precertified by BCBST. Documentation should be specific as to the patient's ability to retain instruction & follow directions to preserve safety. The focus of therapy should be on activities the patient needs within their living environment. Activities of daily living include self maintenance tasks, but are not limited to: Grooming Oral hygiene Bathing, showering Toilet hygiene Dressing Feeding / eating Functional mobility Home management activities include, but are not limited to: Meal preparation & clean up Safety procedures Household maintenance Teaching of compensatory techniques to improve the level of independence should be conducted in conjunction with therapy. Limitations (Services not covered) For treatment of temporary loss or reduction of function (i.e., temporary weakness associated with prolonged rest following major surgery) that would be expected to improve spontaneously with increased normal activity. Enhancement therapy that is designed to improve a patient's condition beyond normal variation in individual development & aging. Occupational Therapy should not be duplicated by Physical Therapy. When occupational therapy & physical therapy are both being received, the therapies should provide different treatments with separate treatment plans & goals. Performance impairments identified during assessment that are not associated with any current or potential functional limitations are to be excluded from the treatment plan. Palliative services as opposed to restorative services that improve function. Orthotic training for use of an orthotic device that is included in the cost of an orthotic device. Activities or programs that are primarily social or diversional in nature. Range of motion & passive exercise not related to restoration of a specific loss of function. Maintenance beyond establishment of a home program. Maintenance therapy is used to delay or minimize muscular deterioration in chronic disease. A maintenance program consists of activities that preserve the patient's present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved or when no additional functional progress is apparent or expected to occur. Occupational therapy required to delay or minimize muscular deterioration for patients suffering from a chronic disease should also be considered maintenance therapy. Assessment Requirements (Evaluation & Plan of Care) Evaluation Ordering MD & last visit Primary diagnosis Date of diagnosis onset Baseline status / current abilities Functional potential Prior level of functioning Diagnostic & assessment services used to ascertain the type, causal factors, & severity of dysfunction or disorders. Support system Developmental delays Other therapies or treatments Patient's goals Medical compliance Prior occupational therapy received & outcome Plan of Care Long & short-term goals Discharge goals Measurable objectives Functional objectives Home program Duration of therapy Frequency of therapy Dates of service Specific modalities & therapy Authorization of Services A limited number of sessions should be authorized initially (i.e., up to 3 times a week for 2 weeks). Greater than 3 visits per week is seldom justified, exceptions must be based on review of both attending physician & OT documentation. Extension requires reevaluation. Evaluation should include the following: Progress being made, level of cooperation, compliance, address DC plans & DC date. Date of last physician visit for this treatment & date extension ordered. Sources BlueCross BlueShield of Tennessee network physicians. April - June 2008.