Occupational therapy services are considered for payment when they are performed to address the need of a patient who is physically disabled due to disease, trauma, congenital anomalies or by condition due to a therapeutic intervention; these services must meet all the following criteria:
· Those services that require the constant attention of a licensed occupational therapist (PT), a doctor of Medicine (MD), doctor of osteopathy (DO) or a chiropractor (DC). This professional will arrive to a diagnosis and will identify those goals that can be reasonably met, will quantify the improvement within a reasonable time predictable.
· Provide an effective reasonable treatment and specific for the diagnosis of the patient and his physical condition.
· These services must be provided by a qualified provider and licensed by the relevant entities.
· These services will be provided as long as measurable progress is demonstrated with possibility of rehabilitation or any other necessary medical objective.
Services that do not meet the above criteria will not be considered for payment. Certain types of treatment that generally do not require the skills of a provider qualified in occupational therapy are not covered for payment. These types of services include:
· Repetitive exercises to improve walking or running or provide resistance to unstable patients.
· Ranges of passive movements (RPOM) not related to the restoration of a loss of specific function.
· Infrared heat, paraffin baths and baths under any circumstances.
· Preventive activities and maintenance.
· Behavior disorder treatment.
· Treatment of mental retardation.
· Treatment of delayed development.
· Treatment when there is no quantifiable progress when it pursues a restorable goal.
· Services beyond those needed to restore the ability to carry out activities of daily living.
· Services in which therapeutic benefits or possibility of improvement are not expected.
· Services in which their duration is predetermined by a specific time rather than the condition of the patient, the results of treatment or medical progress of the patient.
· Services that seek to improve the physical condition of the patient or the repetitive exercises or exercises using equipment to improve the strength and endurance.
· Therapies or services that are considered to be part of custodial services.
· Not supervised services.
· Hospital care is not considered for payment if the admission to the hospital was for the purpose of receiving occupational therapy.
Duplicate therapies are considered when the patient receives physical therapy and occupational therapy on the same day of service and the services are the same. Two therapies must provide different treatments.
Each therapy must have its own goals and treatment plan.
· If a patient visits a provider for physical therapy and another for occupational therapy they count as two visits.
· If a patient visits a provider for physical therapy and occupational therapy they count as one visit.
