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Medical Policy: 08.03.02
Original Effective Date: December 2004
Reviewed: November 2011
Revised: March 2007
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Occupational therapy is defined as the care and services provided by an occupational therapist or a certified occupational therapy assistant under the direction and supervision of an occupational therapist. Occupational therapy (OT) is a form of rehabilitation therapy involving the treatment of neuromusculoskeletal and psychological dysfunction through the use of specific tasks or goal-directed activities designed to improve the functional performance of an individual.
Occupational therapy involves cognitive, perceptual, safety and judgment evaluations and training. These services emphasize useful and purposeful activities to improve neuromusculoskeletal functions and to provide training in activities of daily living (ADL). Activities of daily living include feeding, dressing, bathing, and other self-care activities. Other occupational therapy services include the design, fabrication, and use of orthoses, and guidance in the selection and use of adapted equipment.
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Prior Approval:
Not applicable
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Policy:
Occupational therapy services - which are defined by Wellmark benefit language as services limited to the upper extremities only or for activities of daily living, including infant feeding programs - maybe considered medically necessary when all of the following criteria have been met:
- Meet the functional needs of a patient who suffers from functional impairment due to disease, trauma, congenital anomaly, or prior therapeutic intervention;
- Achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time;
- Provide specific, effective, and reasonable treatment for the patient’s diagnosis and functional condition;
- Will be delivered by a qualified provider of occupational therapy services. A qualified provider is one who is licensed where required and performs within the scope of licensure;
- Require the judgment, knowledge, and skills of a qualified provider of occupational therapy services due to the complexity and sophistication of the therapy and the functional condition of the patient; and
- Are consistent with the current edition of the Physical Medicine Guidelines
 (748 KB) published by Wellmark Blue Cross Blue Shield of Iowa and Wellmark Blue Cross and Blue Shield of South Dakota.
Occupational therapy services are not a covered benefit under any of the following circumstances:
- If the service is excluded from the subscriber benefit certificate;
- The services are determined to be not medically necessary;
- If the service is considered investigational or experimental. A service is considered investigational and experimental when the service, procedure, drug, or treatment has progressed to limited human application, but has not achieved recognition as being proven and effective in the clinical setting. Wellmark Blue Cross Blue Shield of Iowa and Wellmark Blue Cross and Blue Shield of South Dakota determines whether a service is investigational or experimental based on the current scientific literature;
- The service is duplicative of services given by the same or another provider;
- The services are considered non-skilled and do not require the skills of an occupational therapist or certified occupational therapy assistant and therefore are not considered medically necessary; or
- The services are considered to be a maintenance program which consists of activities that preserve the patient’s present level of function and prevents 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.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- Occupational therapy services are found in the Physical Medicine and Rehabilitation section of the AMA Current Procedural Terminology manual. Codes most commonly used to report occupational therapy services are 97003 through 97799. Appropriate CPT codes or HCPCS codes should be accompanied by the correct revenue codes or ICD-9 diagnostic codes.
- Specific service limitations are found in Wellmark’s Physical Medicine Guidelines (April 2011 edition).
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Selected References:
- Physical Medicine Guidelines (April 2011 edition), Wellmark Blue Cross Blue Shield of Iowa and Wellmark Blue Cross Blue Shield of South Dakota.
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Policy History:
Date Reason Action
December 2010 Annual review Policy renewed
November 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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