Subject:

Description

This document provides clinical criteria for the use of outpatient physical therapy, occupational therapy, and speech-language pathology services in the hospital outpatient department or hospital outpatient clinic site of care. Provision of these services in other settings is not addressed in this document.

Note: Please see the following related documents for additional information:

• CG-REHAB-12 Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology

Clinical Indications

Note: The medical necessity of physical therapy, occupational therapy, and speech-language pathology services requested may be separately reviewed against the appropriate criteria. This guideline is for determination of the medical necessity of hospital outpatient site of care for physical or occupational therapy services, or speech-language pathology services.

Medically Necessary:

Outpatient physical therapy, occupational therapy, and speech-language pathology services provided in the hospital outpatient department or hospital outpatient clinic site of care is considered medically necessary when any of the following conditions is present:

1. The prescribed physical therapy, occupational therapy or speech-language pathology regimen requires specialized equipment or services which would only routinely be available in the hospital outpatient department or hospital outpatient clinic setting; or
2. The inherent complexity of, or risk posed by, the prescribed physical therapy, occupational therapy or speech-language pathology regimen is such that it can only be performed safely and effectively by or under the general supervision of skilled medical personnel in the hospital outpatient department or hospital outpatient clinic setting; or
3. The individual's medical status requires enhanced monitoring beyond what would routinely be needed for physical therapy, occupational therapy or speech-language pathology services; or
4. The equipment for the size of the individual (for example, a very young or small child) is not available in a freestanding facility; or
5. There is significant risk of sudden life-threatening changes in the individual’s clinical condition and immediate access to specific services provided in a medical center/hospital setting is considered advisable (for example, access to emergency resuscitation equipment and personnel, inpatient admission or intensive care facilities). Clinical conditions that may warrant such access include, but are not limited to the following:
   1. Acute mental status changes; or
   2. History of falls with significant bleeding; or
   3. History or significant risk of major cardiac event; or
   4. History or significant risk of major thromboembolic event; or
   5. Significant burn care management;
      or
6. There are no other geographically accessible appropriate alternative sites for the individual to receive the prescribed physical therapy, occupational therapy or speech-language pathology regimen.

Not Medically Necessary:

Physical therapy, occupational therapy, and speech-language pathology services in the hospital outpatient department or hospital outpatient clinic site of care are considered not medically necessary, for all other indications, including when criteria above have not been met.

Coding