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Medical Policy

Policy Num:       08.001.003
Policy Name:     HOME BASED OCCUPATIONAL THERAPY 
Policy ID:          [08.001.003][Ac L M+ P+][0.00.00]

Last Review:       November 11, 2020
Next Review:      Archived
Issue:                   November, 2020

Archived

Related Policies: None

HOME BASED OCCUPATIONAL THERAPY 

Summary

Occupational Therapy (OT) is a form of rehabilitation therapy that involves treatment of psychological and neuromusculoskeletal dysfunction through the use of specific tasks or activities designed to improve the functional development of the individual. The concept includes the cognitive, perceptual, security, judgement assessments and training. Activities of daily living include eating, dressing, bathing and other personal care.

General Guidelines for Physical Therapy

Therapy services must be related directly and specifically to a written treatment plan. The plan (also known as a plan of care or treatment plan) must be established before starting treatment.

The professional degree (e.g., MD, OTR / L) of the person who designed the plan and the date of its implementation must be registered with the plan, Outpatient therapy services are provided under a plan established by a physician.  We recommend consultation with physical therapy therapist, occupational therapist or speech-language pathologist. Only a physician can establish a plan of care.

·         The physiotherapist provides physical therapy services

·         The OT will provide occupational therapy services or speech-language pathology services provide speech and language

Treatment must be expressed in minutes with the corresponding code and total treatment time and does not need to be separated by modality.  Progress reports must be combined if possible to make clear that the objectives of each plan are addressed. 

Covered Therapy Services Should: 

Qualify as specialized therapy services:

·         Must be considered under accepted standards of medical practice as a specific and effective treatment for the patient’s condition.

·         Be of a level of complexity and sophistication for the condition of the patient, must be such that the services required can be performed safely and effectively by a qualified therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a qualified therapist.

·         Must be expected that the patient’s condition will improve significantly in a reasonable (and generally predictable) period, or the services must be necessary for the establishment of a safe and effective maintenance program required in connection with a specific disease.  In the case of a progressive degenerative disease, service may be intermittent and necessary, medical equipment necessity should be determined and/ or establish a program to maximize function; and the amount, frequency and duration of the services must be reasonable under accepted standards of medical practice.

o    Therefore, therapy services are covered when rendered.

o    Written treatment plan prepared by the physician, non-medical professionals, optometrist, and/or therapist.

o    To address the specific objectives for which therapeutic modalities and procedures are planned specifically as to the type, frequency and duration, and functional limitations of the patient are documented in terms that are objective and quantifiable. 

General Guidelines for Occupational Therapy

Occupational therapy services are those services provided within the scope of practice of occupational therapists and necessary for the diagnosis and treatment of impairments, functional disabilities or changes in physical function and health status.

 
Occupational therapy is a medical treatment indicated for improving or restoring functions which have been impaired by illness or injury, or its function is lost or reduced by illness or permanent injury, to enhance the individual's ability to perform the tasks required for independent functioning. 

This therapy may involve:

·         Evaluation and re-evaluation, as needed, of function level by administering diagnostic tests and patient prognosis.

·         The selection and education of task-oriented therapeutic activities designed to restore physical function.

·         Planning, implementation and monitoring of programs of therapeutic activities as part of an individualized “active treatment” in the program for a patient with a diagnosed psychiatric illness.

·         The planning and execution of tasks and therapeutic activities to enhance and improve sensory information and response of a stroke patient with functional loss.

·         The teaching of compensation technique to enhance the level of independence in everyday activities such as:

o    teaching a patient who has lost function in one arm to use only one arm for activities such as peeling potatoes and chopping vegetables.

o    Teaching an upper extremity amputee how to use a functional prosthesis or teaching new techniques to a stroke patient so that the patient can feed, clothe and other activities to be as independent as possible.

o     teaching a patient with a hip fracture, balance and equilibrium techniques for the patient to perform functional activities such as dressing and housework tasks using one foot. 

Occupational therapy may be necessary for a patient with a specific psychiatric illness where such services are required and may be covered if the coverage criteria are met.

Occupational therapy can include assessment and professional and pre-professional training.

Occupational therapy can include treatment of functional limitations include those therapies that restore a patient's ability to perform activities of daily living, such as eating, drinking, dressing, bathing, toileting and perform personal hygiene.

 
Other occupational therapy services include the design, manufacture and use of orthoses and guidance in the selection and use of adaptive equipment.

Objective

This evidence based review is performed to evaluate the overall health benefits and outcomes in patient that are housebound and in need of rehabilitation.

Policy Statements

Occupational therapy services home based are considered for payment when performed to address the need for a patient suffering from physical damage due to disease, trauma, congenital anomalies or therapeutic intervention in those homebound insured.

Occupational Therapy services must meet the following criteria:

1.  Fill the functional needs of the patient.

2.  Achieve the goal of improvement in the expected time for the condition or diagnosis of the patient.
3.  Provide specific, reasonable, and effective treatment for the diagnosis and the patient's physical condition.
4. Being offered by a certified professional.

The care plan occupational therapy session should include the following:

1.  State specific goal for the short and long range.
2.  Measurable objectives
3.  A reasonable estimate of when the goal can be achieved.
4.  Specific treatment techniques on activities to be used in the treatment.
5. The frequency and duration of treatment.

Occupational Therapy session (one hour) should include:

1. Basic activities of daily living and self-care.
2. Instructions for developing high level of independence.
3. Program functional exercises for functional limbs.
4. Evaluation and cognitive training, perception and safety.
5. Program for orthotics and prosthetics for upper extremities.
6. Train the patient and family in exercise programs at home.

Policy Guidelines

N/A

Benefit Application

BlueCard/National Account Issues

N/A

Background

For patients with a broad range of serious life-threatening illness, loss of function and independence is a common struggle and a significant contributor to diminished quality of life (QOL) [1-4]. Rehabilitation, even in the advanced phases of an illness, can help to maintain or restore function, permit patients to retain mobility and independence, and improve symptoms, all of which can contribute to a reduced burden on families and caregivers, and better QOL [5]. The main rehabilitation modalities are physical therapy, occupational therapy, and speech and swallowing rehabilitation. Rehabilitation of palliative care patients requires a multidimensional approach to meet the physical, emotional, social, and spiritual needs of patients and their families. All members of the interdisciplinary team should work toward common goals, which are dependent on the patient’s preferences and goals of care.

Regulatory Status

N/A

Rationale

Occupational therapy is a medically prescribed treatment focused on improving or restoring functions that have been impaired by illness, injury, prior therapeutic intervention (eg, hand surgery, joint replacement) or where function has been permanently lost or reduced by disease, trauma, or congenital anomalies. The outcome of therapy is to improve the individual’s ability to perform those tasks or activities of daily living (ADLs) required for independent functioning. The American Occupational Therapy Association (AOTA) describes occupational therapy as services provided for the purpose of promoting health and wellness and to those who have or are at risk for developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction. Occupational therapy addresses physical, cognitive, psychosocial, sensory, communication, and other areas of performance in various contexts and environments in everyday life activities that affect health, well-being, and quality of life.2 Occupational therapy practitioners use their expertise to maximize the fit between what it is the individual wants and needs to do and his/her capacity to do it. The patient’s participation in therapy when coupled with the skilled intervention of the occupational therapy practitioner can often effectively resolve or compensate for health-related functional performance limitations.

In 2007 Legg et al. published a systematic review and meta-analysis of 9 randomized control trials of occupational therapy (OT) delivered to 1258 patients after stroke. The objective was to determine if OT services that focused on personal ADLs improved patients’ recovery after stroke. The data sources used were The Cochrane stroke group trials register, the Cochrane central register of controlled trials, Medline, Embase, CINAHL, PsycLIT, AMED, Wilson Social Sciences Abstracts, Science Citation Index, Social Science Citation, Arts and Humanities Citation Index, Dissertations Abstracts register, Occupational Therapy Research Index, scanning reference lists, personal communication with authors, and hand searching. Two reviewers independently reviewed each trial for methodological quality. Disagreement was resolved by consensus. The results of the review were that OT delivered to patients after stroke and targeted towards personal activities of daily living increased performance scores (standardised mean difference 0.18, 95% confidence interval 0.04 to 0.32, P=0.01) and reduced the risk of poor outcome (death, deterioration or dependency in personal activities of daily living) (odds ratio 0.67, 95% confidence interval 0.51 to 0.87, P=0.003). For every 100 people who received occupational therapy focused on personal activities of daily living, 11 (95% confidence interval 7 to 30) would be spared a poor outcome. The authors concluded stroke patients who receive occupational therapy focused on personal activities of daily living, as opposed to no routine occupational therapy, are more likely to be independent in those activities. 

In 2016, Schneider et al. published a systematic review with meta-analysis of 14 studies of randomized trials. The objective was to determine if increasing the amount of post-stroke physical and occupational rehabilitation would be more beneficial than adding extra rehabilitation of a different type. Their intervention was extra rehabilitation with the same content as usual rehabilitation aimed at reducing activity limitation of the lower and/or upper limb. Of the studies that delivered a large increase in rehabilitation amount, the average dose of usual rehabilitation was approximately 25 minutes per day in the control group and the average dose of extra rehabilitation provided was 260% (ie, 90 minutes per day) in the experimental group. They found a trend towards a positive relationship between extra rehabilitation and improved activity. For example, if a therapy service usually provided 30 minutes of reach and grasp rehabilitation per day, in order to ensure a better outcome, approximately 100 minutes of reach and grasp rehabilitation per day was required. They concluded that at least an extra 240% of rehabilitation was needed for significant likelihood that extra rehabilitation would improve activity. They called for additional randomized trials clarifying the relationship between extra rehabilitation and an improvement in post-stroke activity and recovery.

Population Reference No. 1 Policy Statement

For individuals with impairments, functional disabilities or changes in physical function and health status.  Interventions of interest are rehabilitation therapy for everyday activities.    Comparators of interests are other therapies available. Relevant outcomes include improvement or to restore the ability to perform daily living activities. The evidence is sufficient to determine that this therapy results in a meaningful improvement in the net health outcome.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1.    FreFreedman VA, Martin LG, Schoeni RF. Recent trends in disability and functioning among older adults in the United States: a systematic review. JAMA 2002; 288:3137.
2.    Freedman VA, Martin LG, Schoeni RF. Recent trends in disability and functioning among older adults in the United States: a systematic review. JAMA 2002; 288:3137.
3.    Mann WC, Ottenbacher KJ, Fraas L, et al. Effectiveness of assistive technology and environmental interventions in maintaining independence and reducing home care costs for the frail elderly. A randomized controlled trial. Arch Fam Med 1999; 8:210.

Codes

Appplicable Modifiers

Some modifiers.

Policy History