CMS Outpatient Occupational Therapy Form

Summary Of Evidence

N/A

Analysis of Evidence

N/A

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."

Evaluation of oral and pharyngeal swallowing function

The evaluation of oropharyngeal swallowing dysfunction includes the phases of oral preparatory, oral/voluntary and pharyngeal in reference to oral and motility problems in the oral cavity and pharynx.

The clinical examination may include:

a)  A history of the patient's disorder and awareness of the swallowing disorder, and indications of the localization and nature of the disorder

b) Medical status including nutritional and respiratory status

c) Oral anatomy/physiology (labial control, lingual control, palatal function)

d) Pharyngeal function

e) Laryngeal function

f) Ability to follow directions; alertness

g) Efforts and interventions used to facilitate normal swallow (compensatory strategies such as chin tuck, dietary changes, etc.)

h) Identifying symptoms during attempts to swallow

The clinical examination can be divided into 2 phases:

1. The preparatory examination with no swallow, and
2. The initial swallow examination with actual swallow while physiology is observed

Note: Based on the findings, an instrumental exam may be recommended.

Treatment of swallowing dysfunction and/or oral function for feeding

This involves the treatment for the impairments/functional limitations of mastication, the preparatory phase, oral phase, pharyngeal phase, and esophageal phase of swallowing. Appropriate recommendations will be made regarding diet and compensatory techniques and instruction given in direct/indirect therapies to facilitate oral motor control for feeding.

Muscle testing, manual

Manual testing "are intended to report manual test of muscles or muscle groups for strength based on grading scales."

Muscle testing, manual (separate procedure); extremity (excluding hand) or trunk, with report 

Every muscle of at least 1 extremity would need to be tested, with documentation of why such a thorough assessment was warranted.

Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side 

Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands or including hands 

The measurement of muscle performance using manual muscle testing only.

Range of Motion (ROM) Measurements 

This is the determination of ROM using a tape measure, flexible ruler, electronic device or goniometer.

Every joint of an extremity would need to be tested, with documentation of why such a thorough assessment was warranted for extremity ROM testing.

Developmental Testing; with interpretation and report

Developmental testing are services provided during testing of the cognitive function of the central nervous system. 

Standardized Cognitive Performance Testing 

Neuropsychological testing (e.g., Ross Information Processing Assessment, LOTCA- Loewenstein OT Cognitive Assessment, MVPT - Motor-Free Visual Perception Test, ACL - Allen Cognitive Test), per hour of the OT's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. This is usually done outside the OTs initial evaluation/re-evaluation.

OT Evaluation and OT Re-evaluation

Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions, for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted, e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the POC, including goals and the selection of interventions. The time spent in evaluation does not count as treatment time.

1. The initial examination has the following components:

   a. The patient history to include prior level of function

   b. Relevant systems review

   c. Tests and measures

   d. Current functional status (abilities and deficits)

   e. Evaluation of patient's, physician's, NPP's and as appropriate the caregiver's goals

2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent and duration of loss of function, prior functional level, social/environmental considerations, educational level, and the patient's overall physical and cognitive health status. Thus, the evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. OTs also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, disability, the living environment, prior level of function, the social/cultural supports, psychosocial factors, and use of adaptive equipment.

3. Initial evaluations or re-evaluations may be determined reasonable and necessary, even when the evaluation determines that skilled rehabilitation is not required if the patient's condition showed a need for an evaluation, or even if the goals established by the plan of treatment are not realized.

4. Re-evaluation is periodically indicated during an episode of care when the professional assessment indicates a significant improvement or decline in the patient's condition or functional status that was not anticipated in the POC. Some regulations and state practice acts require re-evaluation at specific intervals. A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals, and/or treatment or terminating services. OTAs may assist the OT in a re-evaluation within their scope of practice by gathering objective data, tests, measurements, etc.; however, the OT must actively and personally participate in the re-evaluation and is responsible for the assessment and the POC.

5. A re-evaluation may be appropriate prior to a planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.

MAINTENANCE PROGRAMS

A maintenance program is a program intended to maintain function or slow the decline in function. Coverage of skilled rehabilitation services is contingent upon a beneficiary’s need for skilled care. When a program to maintain or reduce decline in functional status requires the skills of a licensed therapist to be performed safely and effectively, provision of skilled services for the execution of that therapy program is covered. The skilled need must come from the nature of the service being rendered and the patient’s unique circumstance. The provision of therapy services by skilled therapy personnel does not itself make the service one that requires skilled care.

Hot or Cold Packs Therapy 

Hot or cold packs are used primarily in conjunction with therapeutic procedures to provide analgesia, relieve muscle spasm and reduce inflammation and edema. Typically, cold packs are used for acute, painful conditions, and hot packs are used for subacute or chronic painful conditions.

Mechanical Traction Therapy

1. Traction is generally limited to the cervical or lumbar spine with the hope of relieving pain in or originating from those areas.

2. Specific indications for the use of mechanical traction include:

a. Cervical and/or lumbar radiculopathy
b. Back disorders such as disc herniation, lumbago, and sciatica

Vasopneumatic Device Therapy

1. The use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema.

2. Specific indications for the use of vasopneumatic devices include:

a. Reduction of edema after acute injury
b. Lymphedema of an extremity
c. Education and training on the use of vasopneumatic devices for home use

Note: Further treatment on the use of vasopneumatic devices by OTs, after the education and training visits, is usually not reasonable and necessary. Generally, education and training can be completed in 3 visits.

Paraffin Bath

Paraffin bath, also known as hot wax treatment, is primarily used for pain relief in chronic joint problems or the wrist, hands, and feet.

Heat treatments of this type do not ordinarily require the skills of a qualified OT. However, in a particular case, the skills, knowledge and judgment of a qualified OT might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. Also, if such treatments are given prior to but as an integral part of a skilled OT procedure, the treatments would be considered part of the OT service.

Whirlpool/Hubbard Tank

1. Heat treatments of this type and whirlpool baths do not ordinarily require the skills of a qualified OT. However, in a particular case, the skills, knowledge and judgment of a qualified OT might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. Also, if such treatments are given prior to but as an integral part of a skilled OT procedure, the treatment would be considered part of the skilled OT service.

2. Whirlpool bath and Hubbard Tanks are the most common forms of hydrotherapy. The use of whirlpool is considered reasonable and necessary when used as part of a plan directed at facilitating the healing of an open wound (e.g., burns).

3. Specific indications for the use of whirlpools include the following:

a. The patient having a documented open wound which is draining, has a foul odor, or evidence of necrotic tissue

b. The patient having a documented need for wound debridement/bandage removal

c. Exfoliative skin impairments

Fluidized Therapy Dry Heat For Certain Musculoskeletal Disorders (Dry Whirlpool)

The coverage criteria and definition of fluidized therapy dry heat (dry whirlpool) are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §150.8.

Diathermy Treatment

Diathermy coverage criteria and definition are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §150.5 and Part 4, §240.3.

Infrared Therapy Devices

Noncoverage of Infrared Therapy Devices is described in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §270.6.

Electrical Stimulation 

Electrical stimulation requires "visual, verbal and/or manual contact" (i.e., constant attendance). This requires 1-on-1 instruction for subsequent home use of Transcutaneous Electrical Nerve Stimulation (TENS) unit.

TENS is not reasonable and necessary for the treatment of Chronic Low Back Pain (CLBP) under §1862(a)(1)(A) of the Social Security Act.

Electrical Stimulation Therapy-Unattended

Electrical stimulation therapy and definition are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §270.1.

Electromagnetic Therapy

Electromagnetic therapy criteria and definition are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §270.1.

Iontophoresis Application

1. Iontophoresis is a process in which electrically charged molecules or atoms (i.e., ions) are driven into tissue with an electrical field. Voltage provides the driving force. Parameters, such as drug polarity and electrophoretic mobility must be known in order to be able to assess whether iontophoresis can deliver therapeutic concentrations of a medication at sites below the skin.

2. The application of iontophoresis is considered reasonable and necessary for the topical delivery of medications into a specific area of the body.

3. Specific indications for the use of iontophoresis application may include but are not limited to patients having:

a. Tendonitis or calcific tendonitis

b. Bursitis

c. Adhesive capsulitis

d. Hyperhidrosis

e. Thick adhesive scar(s)

Contrast Baths

1. Contrast baths are a special form of therapeutic heat and cold that can be applied to distal extremities. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold. Although a variety of applications are possible, contrast baths often are used in treatment to decrease edema and inflammation.

2. The use of contrast baths is considered reasonable and necessary to desensitize patients to pain by reflex hyperemia produced by the alternating exposure to heat and cold.

3. Specific indications for the use of contrast baths include:

a. The patient having rheumatoid arthritis or other inflammatory arthritis

b. The patient having reflex sympathetic dystrophy

c. The patient having a sprain or strain resulting from an acute injury

4. Heat treatments of this type and contrast baths do not ordinarily require the skills of a qualified OT. However, in a particular case, the skills, knowledge and judgment of a qualified OT might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. If such treatments were given prior to but as an integral part of a skilled OT procedure, the treatment would be considered part of the skilled OT service.

Ultrasound (US)

1. Therapeutic US is a deep heating modality that produces a sound wave of 0.8 to 3.0 MHz. In the human body, US has several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone can receive an even greater dosage of US, as much as 30% more. Because of the increased extensibility US produces in tissues of high collagen content, combined with the close proximity of joint capsules, tendons, and ligaments to cortical bone where they receive a more intense irradiation, it is an ideal modality for increasing mobility in those tissues with restricted ROM.

2. The application of US is considered reasonable and necessary for patients requiring deep heat to a specific area for reduction of pain, spasm, and joint stiffness, and the increase of muscle, tendon and ligament flexibility.

3. Specific indications for the use of US application include:

a. The patient having tightened structures limiting joint motion that require an increase in extensibility

b. The patient having symptomatic soft tissue calcification

c. The patient having neuromas

Note: US is not considered to be reasonable and necessary for the treatment of asthma, bronchitis or any other pulmonary condition.

GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES:

1. Therapeutic procedures are procedures that attempt to reduce impairments and improve function through the application of clinical skills and/or services.

2. Use of these procedures requires that these services be rendered under the supervision of an OT.

3. Therapeutic exercises and neuromuscular reeducation are examples of therapeutic interventions. The expected goals documented in the written plan of treatment, effected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any 1 or a combination of more than 1 of these procedures may be used in a written plan of treatment, documentation must support the use of each procedure as it relates to a specific therapeutic goal.

4. Services provided concurrently by an OT, PT and speech therapist may be covered, if separate and distinct goals are documented in the written plan of treatment.

5. Require (1-on-1) direct patient contact, unless otherwise stated. 

Therapeutic Exercise

1. Therapeutic exercise is performed with a patient either actively, active-assisted, or passively participating (e.g., isokinetic exercise, stretching, strengthening and gross and fine motor movement).

2. Therapeutic exercise may address impairments of exercise tolerance due to cardiopulmonary impairments. Therapeutic exercise with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations secondary to cardiopulmonary impairments.

3. Therapeutic exercise is considered reasonable and necessary if at least 1 of the following conditions is present and documented:

a. The patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint ROM, functional mobility deficits, balance and/or coordination deficits, abnormal posture, muscle imbalance

b. The patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, ROM, or endurance as part of ADL training, or reeducation

4. Documentation for therapeutic exercise typically includes objective loss of joint motion, strength, and /or mobility (e.g., degrees of motion, strength grades, levels of assistance).

Neuromuscular Reeducation

1. This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, motor planning, body awareness, and proprioception (e.g., proprioceptive neuromuscular facilitation, Feldenkrais, Bobath).

2. Neuromuscular reeducation may be considered reasonable and necessary for impairments, which affect the body's neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, desensitization, proprioception, hypo/hypersensitivity, hypo/hypertonicity, and neglect).

Aquatic Therapy with Therapeutic Exercises

"Aquatic therapy describes therapeutic exercises performed in a water-based environment. The properties and temperature of the water facilitate movement, particularly for muscles that are compromised due to injury, surgery, or disease (e.g., polio, rheumatoid arthritis, multiple sclerosis, joint arthroplasty)." It is important for the OT to document the need for exercises performed in a water-environment vs. land-based exercise. There should be a plan for transitioning from water-based exercises to land-based exercises.

1. This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). The procedure may be reasonable and necessary for a loss or restriction of joint motion, strength, or mobility (e.g., degrees or motion, strength grades, levels of assistance).

2. Aquatic therapy with therapeutic exercise may be considered reasonable and necessary in the treatment of the following conditions:

a. The patient having pain, joint stiffness or muscle spasms resulting from rheumatoid arthritis

b. The patient having had a cast removed or recent surgery and requiring mobilization of limbs

c. The patient having paraparesis or hemiparesis

d. The patient having a recent amputation

e. The patient recovery from a paralytic condition

f. The patient requiring limb mobilization after a head trauma

g. The patient having the inability to tolerate exercise for rehabilitation under gravity-based weight bearing

h. The patient having fibromyalgia

Massage Therapy

1. Massage is the application of systemic manipulation to the soft tissues of the body for therapeutic purposes. Although various assistive devices and electrical equipment are available for the purpose of delivering massage, use of the hands is considered the most effective method of application, because palpation can be used as an assessment, as well as a treatment tool.

2. Massage therapy, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) may be considered reasonable and necessary if at least 1 of the following conditions is present and documented:

a. The patient having paralyzed musculature contributing to impaired circulation

b. The patient having sensitivity of tissues to pressure

c. The patient having tight muscles resulting in shortening and/or spasticity of affective muscles

d. The patient having abnormal adherence of tissue to surrounding tissue

e. The patient requiring relaxation in preparation for neuromuscular reeducation or therapeutic exercise

f. The patient having contractures and decreased ROM

Manual Therapy Techniques 

1. Joint Mobilization (Peripheral or Spinal)

This procedure may be considered reasonable and necessary if restricted joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.

2. Soft Tissue Mobilization

This procedure involves the application of skilled manual therapy techniques (active or passive) to soft tissues in order to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples are facilitation of fluid exchange, restoration of movement in acutely edematous muscles, or stretching of shortened muscular or connective tissue.

Myofascial release/soft tissue mobilization can be considered reasonable and necessary if at least 1 of the following conditions is present and documented:

a. The patient having restricted joint or soft tissue motion in an extremity, neck or trunk

b. Treatment being a necessary adjunct to other OT interventions 

3. Manipulation

This procedure may be considered reasonable and necessary for treatment of painful spasm, the loss of articular motion, or restricted motion of soft tissues or joints. It may also be used as an adjunct to other therapeutic procedures. 

4. Manual Lymphatic Drainage/Complex Decongestive Physiotherapy

The goal of this type of therapy is to reduce lymphedema by routing the fluid to functional pathways, preventing backflow as the new routes become established, and to use the most appropriate methods to maintain the reduction after therapy is complete. This therapy involves intensive treatment to reduce the size by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program.

a. It is expected that during these sessions, education is being provided to the patient and/or caregiver on the correct application of the compression bandage

b. It is also expected that after the completion of the therapy, the patient and/or caregiver can perform these activities without supervision

Group Therapeutic Procedure(s)

A group for the purpose of performing group therapy will be defined as:

a. Two or more patients per therapist receiving active therapy but not 1-on-1 treatment, and

b. The patients may be performing the same exercise or a different exercise, but the OT is instructing all the patients in the group.

Note: Regardless of the procedure or modality being performed, if the patient is not receiving direct 1-on-1 contact but is being supervised by the therapist it is considered the group therapy. 

Orthotics Training 

1. This procedure may be considered reasonable and necessary, if there is an indication for education for the application of orthotics, and the functional use of the orthotic is present and documented.

2. Generally, orthotic training can be completed in 3 visits; however, for modification of the orthotic due to healing of tissues, change in edema, or impairment in skin integrity, additional visits may be required.

3. The medical record should document the distinct treatments rendered when orthotic training for an upper and/or lower extremity is done.

4. The patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, the patient may not be able to perform this function, but a responsible individual can be trained to apply the device.

Prosthetic Training 

1. This procedure and training may be considered reasonable and necessary, if there is an indication for education in the application of the prosthesis, and the functional use of the prosthesis is present and documented.

2. The medical record should document the distinct goals and service rendered when prosthetic training for an upper and/or lower extremity is done.

3. Periodic revisits beyond the third month would require documentation to support medical necessity.

Orthotic/Prosthetic Checkout

1. These assessments are reasonable and necessary when there is a modification or reissue of a recently issued device or a reassessment of a newly issued device.

2. These assessments may be reasonable and necessary when patients experience a loss of function directly related to the device (e.g., pain, skin breakdown, and falls).

3. These assessments may be reasonable and necessary for determining "the patient's response to wearing the device, determining whether the patient is donning/doffing the device correctly, determining the patient's need for padding, under wrap, or socks and determining the patient's tolerance to any dynamic forces being applied."

Therapeutic Activities

1. Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques. Activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities to improve performance in a progressive manner. The activities are usually directed at a loss or impairment of mobility, strength, balance, coordination or cognition. They require the skills of an OT and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active written plan of treatment and be directed at a specific outcome.

2. In order for therapeutic activities to be covered, the following requirements must be met:

a. The patient having a condition for which therapeutic activities can reasonably be expected to restore or improve functioning

b. The patient's condition being such that he/she is unable to perform therapeutic activities except under the supervision of an OT

c. There being a clear correlation between the type of exercise performed and the patient's underlying medical condition for which the therapeutic activities were prescribed

Cognitive Skills Development

1. This procedure is reasonable and necessary for patients who have a disease or injury in which impairment of cognitive functioning is documented. Impaired functions may include, but are not limited to:

• ability to follow simple commands
• ability to focus on a task
• improve problem solving skills
• improve memory
• ability to follow numerous steps in a process
• ability to complete a logical sequence task
• ability to organize parts of concepts or thoughts into a whole

2. This procedure is reasonable and necessary only when it requires the skills of an OT and is designed to address specific needs of the patient and is part of the written POC.

3. Treatment techniques utilized include, but are not limited to: recall of information, tabletop graded activities focusing on attentional skills (e.g., cancellation tasks, mazes), graded processes in steps which the patient must follow to complete the task, and computer programs that focus on the above.

4. Development of cognitive skills must be reasonable and necessary to restore and improve functioning of the patient. Documentation must relate the training to expected functional goals that are attainable by the patient.

5. Services provided concurrently by physicians, NPPs, OTs and speech therapists may be covered, if separate and distinct goals are documented in the written plan of treatment.

Sensory Integrative Techniques

The use of sensory integrative techniques is considered reasonable and necessary when patients must develop adaptive skills for sensory processing. When there has been a disruption of the auditory, vestibular, proprioceptive, tactile and/or visual system, interventions are required to assist the patient in remaining functional in their environment. The loss of sensory systems often compromises the safety of the patient; therefore, therapy should provide adaptations that allow the patient to interact with their environment to promote well-being.

Self-Care/Home Management Training

The coverage criteria of self-care/home management training is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 3, §170.1.

"Self-care/home management training describes a group of interventions that focuses on ADL skills and compensatory activities needed to achieve independence or adapt to an evolving deterioration in health and function. These include activities such as dressing, bathing, food preparation, and cooking. The patient/client may require adaptive equipment and/or assistive technology in the home environment. This includes training the patient/client and/or caregiver in the use of the equipment." 

Community/Work Reintegration Training

Services that are related solely to specific employment opportunities, work skills, or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by §1862(a)(1)(A) of the Social Security Act.

Services that are covered include complex IADLs a person must do to maintain independence in the community. These tasks involve interaction with the physical and social environment. Examples of these activities may include telephone skills, written communication, handling mail, use of money, shopping, emergency procedure use/skills and use of assistive technology device/adaptive equipment. This service is only covered when the skilled intervention of OT is required to achieve established goals.

Work Hardening/Conditioning

"Work hardening and work conditioning are different interventions. Work hardening is an interdisciplinary program that is focused on tasks required for a specific job and uses real or simulated work activities to restore physical, behavioral, and vocational functions. Work hardening addresses productivity, safety, physical tolerances, and worker behavior. In contrast, work conditioning describes a work-related, intensive treatment program designed to restore strength, flexibility, and function so that the patient/client can return to work." These interventions are not covered.

Wheelchair Management Training 

Wheelchair management "includes assessing if the patient/client needs a wheelchair, determining what kind of wheelchair is appropriate, including its size and components, measuring the patient/client to ensure proper fit, and fitting the patient/client into the chair once it is received. It also includes time associated with training the patient/client and/or caregiver in transfers in and out of the chair as well as propulsion on all surfaces. It is important for the therapist to provide instructions for safety so as not to risk skin breakdown or a fall."

1. This service trains the patient in functional activities that promote optimal safety, mobility and transfers. Patients who use wheelchairs for mobility may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications.

2. This procedure is reasonable and necessary only when it requires the skills of an OT and is designed to address specific needs of the patient and must be part of an active written plan of treatment directed at a specific goal.

3. The patient and/or caregiver must have the capacity to learn from instructions.

4. Typically, 3 to 4 sessions should be sufficient to teach the patient and/or caregiver these skills.

5. For wheelchair propulsion training, documentation should relate the training to expected functional goals that are attainable by the patient.

Wound Care Selective Debridement 

a) Debridement

Debridement is indicated whenever necrotic tissue is present on a documented open wound. Debridement may also be indicated in cases of abnormal wound repair. Debridement techniques usually progress from non-selective to selective but can be combined. Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue.

b) Conservative Sharp Debridement

Conservative sharp debridement is a minor procedure that requires no anesthesia and is performed on an outpatient basis. Scalpel, scissors, forceps and high-pressure waterjet may be used and only clearly identified devitalized tissue is removed. Generally, there is no bleeding associated with this procedure.

Wound(s) Care Non-Selective Debridement and Negative Pressure Wound Therapy 

a) Enzymatic Debridement

Debridement with topical enzymes is used when necrotic substances to be removed from a wound are protein, fibrin and collagen. The manufacturer's product insert contains indications, contraindications, precautions, dosage, and administration. It would be the clinician's responsibility to comply with the product insert/guidelines.

b) Autolytic Debridement

This type of debridement is indicated where manageable amounts of necrotic tissue are present, and there is no infection. Autolytic debridement occurs when the enzymes that are naturally found in wound fluids are sequestered under synthetic dressings. Autolytic debridement is contraindicated for wounds that contain infection.

c) Mechanical Debridement

Wet-to-moist dressings may be used with wounds that have a high percentage of necrotic tissue. Wet-to-moist dressings should be used cautiously as maceration of surrounding tissue may hinder healing.

Hydrotherapy and wound irrigation are also forms of mechanical debridement used to remove necrotic tissue. They also should be used cautiously, as maceration of surrounding tissue may hinder healing.

d) Negative Pressure Wound Therapy

Negative Pressure Wound Therapy is a non-invasive treatment, by which controlled localized negative pressure is delivered to a wide variety of acute, sub-acute, and chronic wounds. Negative Pressure Wound Therapy should be used cautiously as maceration of surrounding tissue may hinder healing.

Physical Performance Test or Measurement

This testing may be reasonable and necessary for patients with neurological or musculoskeletal conditions, when such tests are needed to formulate or evaluate a specific written plan of treatment, or to determine a patient's functional capacity.

Assistive Technology Assessment

This assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s). Assessment determines, e.g., changes in the patient's status since the last visit and whether the planned procedure or service should be modified. Based on these assessment data, the professional may make judgment about progress toward goals and/or determine that a more complete evaluation or re-evaluation is indicated.