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Tricare Occupational Therapy

Description of Services

Occupational therapy is the prescribed use of specific purposeful activity or interventions designed to promote health, prevent injury or disability, and which develop, improve, sustain, or restore functions which have been lost or reduced as a result of injury, illness, cognitive impairment, psychosocial dysfunction, mental illness, or developmental, learning or physical disability(ies), to the highest possible level for independent functioning.

Policy

Occupational therapy prescribed and supervised by a physician, certified Physician Assistant (PA) working under the supervision of a physician, or certified Nurse Practitioner (NP) is covered.

Occupational therapy to improve, restore, or maintain function, or to minimize or prevent deterioration of function of a patient when prescribed by a physician is covered in accordance with the rehabilitative therapy provisions.

Maintenance Therapy Programs

The specialized knowledge of a skilled provider may be required to establish a maintenance program intended to prevent or minimize deterioration caused by a medical condition. Establishing such a program is a skilled service. The initial evaluation of the patient’s needs, the designing by a skilled provider of a maintenance program which is appropriate to the capacity and tolerance of the patient, the instruction of the patient or family members in carrying out the program and infrequent evaluations may be required.

Rehabilitative Therapy Programs

While a patient is under a restorative rehabilitative therapy program, the skilled provider should reevaluate his/her condition when necessary and adjust any exercise program that the patient is expected to carry out himself/herself or with the aid of family members to maintain the function being restored. Consequently, by the time it is determined that no further restoration is possible, i.e., by the end of the last restorative session, the provider will have already designed the maintenance program required and instructed the patient or family member in the carrying out of the program. Therefore, where a maintenance program is not established until after the restorative rehabilitative therapy has been completed, it would not be considered medically necessary and appropriate medical care and would be excluded from coverage.

Once a patient has reached the point where no further significant practical improvement can be expected, the skills of an authorized provider will not be required in the carrying out of an activity/exercise program required to maintain function at the level to which it has been restored. The services of a skilled provider in designing a maintenance program will be covered, carrying out the program is not considered skilled care, medically necessary or appropriate medical care consequently such services are not covered.

Services Not Covered

The following occupational therapy services are not covered:

    • Vocational assessment and training.
    • General exercise programs.
    • Separate charges for instruction of the patient and family in therapy procedures.
    • Repetitive exercise to improve gait, maintain strength and endurance, and assisted walking such as that provided in support of feeble or unstable patients.
    • Maintenance therapy that does not require a skilled level after a therapy program has been designed.
    • Range of motion and passive exercises which are not related to restoration of a specific loss of function.
    • Sensory integration therapy (CPT2 procedure code 97533) which may be considered a component of cognitive rehabilitation is unproven.
Note: This policy does not exclude multidisciplinary services, such as physical therapy, occupational therapy, or speech therapy after traumatic brain injury, stroke and children with an autistic disorder.
    • Occupational therapists are not authorized to bill using Evaluation and Management (E&M) codes listed in the Physicians’ Current Procedural Terminology (CPT).
    • For beneficiaries under the age of three, services and items provided in accordance with the beneficiary’s Individualized Family Service Plan (IFSP) as required by Part C of the Individuals with Disabilities Education Act (IDEA), and which are otherwise allowable under the TRICARE Basic program or the Extended Care Health Option (ECHO) but determined not to be medically or psychologically necessary, are excluded.
    • For beneficiaries aged three to 21, who are receiving special education services from a public education agency, cost-sharing of outpatient occupational therapy services that are required by the IDEA and which are indicated in the beneficiary’s Individualized Education Program (IEP), may not be cost-shared except when the intensity or timeliness of occupational therapy services as proposed by the educational agency are not sufficient to meet the medical needs of the beneficiary.

CPT Codes

97003 - 97004, 97127, 97150, 97533, 97535, 97799

Citation

Tricare Policy Manual Ch. 7 Sec. 18.1 and 18.3

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