The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Services for Children and Youth in Education and Early Childhood Programs
This rule applies to all occupational therapy practitioners who include both occupational therapists and occupational therapy assistants. All other rules regarding Occupational Therapy practitioners apply notwithstanding what is found in these rules as they apply to practitioners in the education setting.
“Children and youth” refers to a child or student determined to be eligible for services under IDEA or Section 504. Part B under IDEA describes requirements for the provision of special education services for preschool and school-age children and youth, ages 3 through 21 years. Part C, or the early intervention program, focuses on services for infants and toddlers with disabilities and their families. Section 504 and the Americans With Disabilities Act (ADA 1990) define a person with a disability as “any person who has a physical or mental impairment that substantially limits one or more major life activities…” and require a public school system to provide needed accommodations or services.
“Service plans” document the program of services and supports necessary to meet a child’s developmental or educational needs under the IDEA. These specify the need for occupational therapy services and include: the individualized family services plan (IFSP) for infants, toddlers and preschoolers; the individualized education plan (IEP) or a Section 504 Plan for school-age youth.
“Educational or developmental goals” are developed collaboratively by a multi-disciplinary early intervention or educational team, which includes an occupational therapist as a related service provider, when areas of occupational performance have been identified.
“Natural environment” refers to the most appropriate setting for the child to develop the skills needed for occupational performance.
“Educational environments” refers to home; community; day care; preschool, or the general and special education settings.
“Evaluation” is the process of gathering information to make decisions about a student’s or child’s strengths and educational or developmental needs.
“Assessments” are the specific methods or measures used to gather data for the evaluation.
The Occupational Therapy Process
The occupational therapist is responsible for the occupational therapy evaluation.
The occupational therapy practitioner may implement occupational therapy services, along a continuum, which may include the following:
The occupational therapist should review the intervention on an ongoing basis and dependent on the child’s response, modify as needed.
Delegation of Therapeutic Activities
The occupational therapy practitioner may instruct others, such as educational or daycare staff, to carry out a specific activity or technique designed to support the child’s the performance.
The designated person must be able to demonstrate the technique as instructed, recount the restrictions, safety factors and precautions.
The occupational therapy practitioner is responsible for ongoing monitoring of the trained person and modifying the procedures based on outcomes and other changes.
When considering the delegation of techniques the child’s health and safety must be maintained at all times.
The occupational therapy practitioner must document evaluation, goals, interventions and outcomes if they are not included in the service plan.
Documentation should reflect the child’s current status, progress towards goals, response to interventions, and strategies that were promising or ineffective.
The occupational therapist should utilize a method of data collection that allows for concise and accurate recording of intervention and progress.
The occupational therapy practitioner is responsible for the analysis of data collected to verify progress and the documentation of their own activities to accomplish the goals.
School records shall be kept for a minimum of seven (7) years.