Occupational Therapy (OT) is the treatment of neuromusculoskeletal and psychological dysfunction, caused by disease, trauma, congenital anomaly, or prior therapeutic process, through the use of specific tasks or goal-directed activities designed to improve functional performance of the individual. OT services emphasize useful and purposeful activities to improve neuromusculoskeletal function and to provide training in activities of daily living (ADL).

Pennsylvania State Mandate (Act 62 – 2008) Autism Spectrum Disorders Coverage Mandate Effective July 1, 2009 requires coverage for individuals for the diagnostic assessment and treatment of ASD.

Pennsylvania State Mandate (Act 90-2012) Occupational Therapy Practice Act - July 5, 2012.   Explicitly allows occupational therapists (OTs) to design, fabricate, and apply orthotics. 

OT may be considered medically necessary for individuals who meet ALL of the following criteria:

• The therapy is aimed at improving, adapting, or restoring functions of an individual who has been impaired or permanently lost as a result of physical disability due to illness, injury, congenital anomaly, or prior therapeutic intervention; and
• Achieve a specific diagnosis-related goal for an individual who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time based on the qualified OT assessment of the individual’s restoration potential and unique medical condition; and
• Specific, effective, and reasonable treatment for the individual’s diagnosis and physical condition; and
• The services are delivered by a qualified provider of OT services. 

A qualified provider is an individual who is licensed, where required, and performs within the scope of licensure.

A typical treatment plan consists of up to one (1) hour sessions and up to four (4) physical medicine procedures per date of service and includes ANY of the following:

• Modalities; or
• Therapeutic procedures; or
• Tests and measurements; or
• Muscle range of motion (ROM) testing; or
• Orthotic management and prosthetic management.

Exceptions include standardized cognitive performance testing per hour and work hardening/conditioning; initial two (2) hours.

Only one (1) of these services are eligible for reimbursement per date of service since each represents one (1) hour or greater of OT testing or treatment.

Each additional hour of work hardening/conditioning will be considered exceeding the limitation and is considered not medically necessary.

No other physical medicine procedure codes can be billed on the same date of service.

Duplicate therapy is considered not medically necessary. Example: An individual receiving therapy services from two (2) different providers treating the same condition.

An evaluation and management (E/M) service is considered an inherent part of an OT evaluation. The E/M service is not eligible for separate reimbursement when reported on the same day as an OT evaluation.

When an E/M service is reported in conjunction with an OT evaluation, the services should be combined under the appropriate code for the OT evaluation.

Muscle testing, ROM testing, and physical performance testing are considered components of an OT evaluation. They are not eligible for separate reimbursement when billed with an OT evaluation. 

Maintenance Therapy

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.   

A maintenance program consists of activities that preserve the individual’s present level of function and prevent regression of that function. These services would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness.  

Maintenance therapy may be reported under physical or manipulative therapy performed for maintenance rather than restoration, and is not eligible for reimbursement unless the individual has habilitative services benefits.

Habilitative Therapy

Habilitative therapy services may be considered medically necessary when the following criteria are met:

• Ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury; and/or
• Includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

Note:

Habilitative therapy is not eligible for reimbursement unless the member has a habilitative benefit.  

Spinal manipulation is not considered a habilitative service.

Habilitative services not meeting the criteria as outlined in this policy are considered not medically necessary.

2012 Act 90 Occupational Therapy Practice Act - July 5, 2012

Explicitly allows occupational therapists (OTs) to design, fabricate, and apply orthotics.

Occupational Therapy is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.