LCD L34427: Outpatient Occupational Therapy

Although rehabilitative services are provided by occupational therapy (OT), speech therapy and physical therapy (PT), this policy only addresses OT.

OT is an integral component of rehabilitative services in the areas of physical, cognitive and psychosocial impairment. OT is based on purposeful, goal directed activity (occupation). The goal of OT is to prevent, improve or restore physical and/or cognitive impairment following disease or injury. Occupational therapists (OTs) utilize clinical history, observation, interview, standardized testing and assessment of activities of daily living skills (ADLs), work skills, and leisure skills to characterize individuals with impairments, functional limitations and disabilities. The results of these assessments are used to identify structural impairments and functional limitations and to design an individualized plan of treatment to assist in improving or restoring function. All OT services must be performed by or under the supervision of a qualified OT.

For the purposes of this Local Coverage Determination (LCD), the descriptions/definitions of supervision are those given in 42 CFR §410.32(b)(3).

Qualified OT: An individual who is licensed as an OT and meets the practice requirements in the state where they are practicing.

For outpatient settings, references to “physicians” throughout this policy include nonphysician practitioners (NPPs), such as nurse practitioners, clinical nurse specialists and physician assistants. Such NPPs may certify, order and establish the plan of care (POC) for services by OTs as authorized by state law.

A qualified OT, for program coverage purposes, is defined as an individual who is licensed as an OT and meets the practice requirements in the state where they are practicing. Physiatrists, physicians or NPPs, and qualified OTs have the knowledge, training, and experience required to evaluate and, as necessary, re-evaluate a patient’s level of function, and determine whether an OT program could reasonably be expected to improve, restore or compensate for lost function. Where appropriate, the OT can recommend to the physician or NPP a POC. While the skills of a qualified OT are required to evaluate the patient’s level of function and develop a POC, implementation of the plan may also be carried out by a qualified occupational therapy assistant (OTA) functioning under the general supervision of the qualified OT.

NOTE: Some services must be provided by a licensed therapist and may not be performed by an OTA. Such services include:

• Making clinical judgements or decisions

• Developing, managing or furnishing skilled maintenance programs

• Supervising other clinicians or taking responsibility for the service rendered

• Acting outside of the direction and supervision of a treating OT in accordance with state laws

Restorative/Rehabilitative therapy:

In evaluating a claim for skilled therapy that is restorative/rehabilitative (i.e., whose goal and/or purpose is to reverse, in whole or in part, a previous loss of function), it would be entirely appropriate to consider the beneficiary’s potential for improvement from the services. The Centers for Medicare & Medicaid Services (CMS) notes that such a consideration must always be made in the inpatient rehabilitation facility (IRF) setting where skilled therapy must be reasonably expected to improve the patient’s functional capacity or adaptation to impairments in order to be covered.

Maintenance therapy:

A maintenance program is a program designed to maintain or to slow deterioration as described in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220 and §220.2 and must meet these criteria to be considered reasonable and necessary.

The treatment approach includes:

a) evaluation

b) basic activities of daily living (BADLs) training

c) instrumental activities of daily living (IADLs) training

d) muscle reeducation/strengthening/coordination

e) cognitive training

f) perceptual motor training

g) orthotics (splinting)

h) adaptive equipment fabrication and training

i) environment modification recommendations/training

j) patient/caregiver education/training

k) transfer training

l) functional modality training

m) manual therapy

n) physical agent modality

GENERAL OT GUIDELINES

1. OT services are covered services provided the services are of a level of complexity and sophistication, or the patient's condition is such that the services can be safely and effectively performed only by a licensed OT or under his/her supervision. Services normally considered a routine part of nursing care are not covered as OT (i.e., provide ADLs for patient with no rehabilitation potential).

2. In order for the plan of treatment to be covered, it must address a condition for which OT is an accepted method of treatment as defined by standards of medical practice. Also, the plan of treatment must be for a condition that is expected to improve significantly within a reasonable and generally predictable period of time or establishes a safe and effective maintenance program. If at any point in the treatment of an illness or injury it is determined that the treatment is not rehabilitative or does not legitimately require the services of a qualified professional for management of a maintenance program, the services will no longer be considered reasonable and necessary and are excluded from coverage.

3. Covered OT services must be furnished while the individual is or was under the care of a physician. Services must relate directly and specifically to a written plan of treatment. The plan of treatment should address specific therapeutic goals, for which modalities and procedures are planned out specifically in terms of type, frequency and duration. The physician or NPP should periodically review the plan of treatment.

4. The physician, NPP and/or therapist must document the patient's functional limitations in terms that are objective and measurable.

SPECIFIC PROCEDURE AND MODALITY GUIDELINES

Computerized Dynamic Posturography

Computerized dynamic posturography is a "quantitative method for assessing balance functioning under various simulated tasks. Protocols are designed to test the sensory, motor and biomechanical components of balance individually and in concert." Computerized dynamic posturography "may assist with lesion localization, identifying adaptive strategies and functional capabilities."

*Note: Results of computerized dynamic posturography must be used in determining the patient centered POC.

Fabrication/Application of Casts, Splints and Strapping

Fabrication and application of casts, splints, and strapping will be considered reasonable and necessary if used to support weak, post-surgical or ineffective joints/muscles, for facilitating increased motor response, to assist in compensation in a permanent loss of motor function, reduce/correct joint limitations/deformities and/or protect body parts from injury, thus enhancing the performance of tasks or movements. The casts, splints and strapping are often used in conjunction with therapeutic exercise, functional training, other interventions, and should be selected in the context of patient's needs, social/culture environments, BADLs and IADLs.

BODY AND UPPER EXTREMITY CASTS

Application of long arm cast

May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue.

Application of short arm cast

May be indicated for the forearm, wrist, and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue.

Application of hand and lower forearm cast

May be indicated for the forearm, wrist, and/or hand in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue.

Application of finger cast (e.g., contracture)

May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, treatment of spasticity, contractures and/or other deformities involving soft tissue.

SPLINTS

Application of long arm splint

May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, treatment of spasticity, contractures or other deformities involving soft tissue.

Application of short arm splint

May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprain/strains, tendonitis, post-op reconstruction, treatment of spasticity, contractures or other deformities involving soft tissue.

Application of finger splint

May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, treatment of spasticity, contractures or other deformities involving soft tissue.

STRAPPING-ANY AGE

Strapping of thorax

May be indicated for the thoracic spine, lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures, or other deformities involving soft tissue.

Strapping of low back

May be indicated for the lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprain/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of shoulder (e.g., Velpeau)

May be indicated for any portion of the shoulder girdle complex, or rib cage in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of elbow or wrist

May be indicated for the elbow or wrist when there is involvement of the humerus, forearm, wrist, or hand in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, edema, scar management, contractures or other deformities involving soft tissue.

Strapping of hand or finger

May be indicated where there is involvement of the hand or finger(s) in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, edema, scar management, contractures or other deformities involving soft tissue.

LOWER EXTREMITY CASTS

Application of long leg cast

May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Application of short leg cast

May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

SPLINTS

Application of long leg splint

May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Application of short leg splint

May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

STRAPPING ANY AGE

Strapping of hip

May be indicated when there is involvement of the lower back, abdomen or hip in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of knee

May be indicated when there is involvement of the thigh, knee or lower leg in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of ankle and/or foot

May be indicated when there is involvement of the lower leg, ankle and/or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of toes

May be indicated when there is involvement of any of the toes in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Biofeedback Training by any method and biofeedback training perineal muscles, anorectal or urethral sphincter including EMG and/or manometry

The coverage criteria and definition of biofeedback therapy are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §30.1 and §30.1.1.

"Biofeedback is a tool utilized by OTs to assist with muscle training. This includes facilitation of muscles that are demonstrating suboptimal performance as well as relaxation of muscles that may be inhibiting coordinated movement. Biofeedback can be visual or auditory."

N/A